Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Febreeze and laundry detergent were unlocked in Individual #1's bedroom. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The laundry detergent and febreeze were moved to the laundry room, which is kept locked.
See attachment L
All Residential Supervisors and Program Specialists were re-trained that despite the fact that the laundry detergent was on a high shelf in the individual¿s bedroom, that they could not assume that another individual in the home who does not have adequate awareness of poisonous materials could not gain access if they tried. They were re-trained to simply keep everything locked that could be considered poisonous. Program Specialists will monitor this during site visits.
See attachment A |
10/12/2016
| Implemented |
6400.67(a) | Individual #2's dresser was missing a knob on the fourth drawer. | Floors, walls, ceilings and other surfaces shall be in good repair. | Knob was replaced on the dresser.
See attachment K
All Residential Supervisors and Program Specialist level staff were trained on the need to be more mindful of furniture knobs. Program Specialists now look for this during their monthly site visits.
See attachment A |
10/12/2016
| Implemented |
6400.110(f) | Individual #1's bedshaker was inoperable when the smoke detectors were set off. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | When this was discovered during the licensing inspection Penn-Mar¿s maintenance team was immediately contacted. The unit was assessed and it was determined that it could not be repaired and that a new unit needed to be purchased. The new unit arrived and was installed on October 18, 2016. During the time that the shaker was not working and the new unit arrived, staff checked on Individual #1 and did a walk-through of the home every 15 minutes to ensure that the home was safe. There is documentation of these 15 minute checks.
See attachment B & J
Attached you will find October and November 2016¿s fire drill form which shows the shaker was working during the fire drill in November.
See attachment I
Bed shakers are checked every month by staff during fire drills and by Program Specialists during house inspections. The bed shaker was working when it was checked in September. Regardless of this fact, all Residential Supervisors and Program Specialists were reminded that they need to be checking these adaptive devises each month and documenting that on the fire drill form and the site monitoring form. The protocol for what needs to occur if a unit is not functioning was also reviewed.
See Attachment A |
10/18/2016
| Implemented |
6400.112(d) | The 10/14/15 fire drill log indicated an evacuation time of 2 minutes and 45 seconds. The 4/14/16 fire drill log indicated an evacuation time 2 minutes and 46 seconds. The 8/24/16 fire drill log indicated an evacuation time of 2 minutes and 36 seconds. An extended evaucation time of 3 minutes and 30 seconds was not implemented until 9/1/16. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | On August 24, 2016 a fire inspector came to the home to inspect the home to determine a safe fire evacuation time. We received this letter on September 1, 2016. September, October, and November¿s fire drills show that the drills were successfully completed within the new fire evacuation time.
See attachment I
All Residential Supervisors and Program Specialist staff were trained on the process that needs to occur if a home is struggling to evacuate within 2 ½ minutes or within the approved extended evacuation time. There needs to be a timelier dialog so that extended evacuation times can either be requested or if individuals are struggling to be evacuated within the extended evacuation time, there needs to be immediately intervention to assist with this problem. Interventions may need to include adding staffing hours if the situation is severe enough.
See attachment A |
11/27/2016
| Implemented |