Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.46(a) | Staff #1, #2, and #3 were not oriented to their job responsibilities or daily operation procedures. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | I believer there may be a misunderstanding regarding Staff #1 and Staff #3. Attached you will find the signed job descriptions for Staff #1 and Staff #3 from orientation as well as their Individual specific training packet. It does appear that Staff #2 did not sign off on a job description at orientation. This occurred in January 2016. This employee was hired as Substitute staff, and the HR department did not provide a job description to this staff. This has since been corrected, as evident by the fact that Staff #3 was also hired as a Substitute staff on June 20, 2016 and she did sign a job description. You will find all the documents for Staff #1 and #3 attached.
See Attachment AI
In addition, since this licensing we have had a new staff start on November 7, 2016 and sign a job description at Orientation. This staff also completed Individual specific training between November 7, 2016 and November 25, 2016
See Attachment AJ |
11/25/2016
| Implemented |
6400.67(a) | Individual #1's bedroom had numerous small holes in the walls from hanging items. | Floors, walls, ceilings and other surfaces shall be in good repair. | Penn-Mar¿s maintenance department patched the wall that had the small holes from previous items that had been hanging in this room.
See attachment B
All Residential Supervisors and Program Specialist level staff were re-trained on the fact that even small holes should be patched in a timely manner. Supervisors and Specialists were trained to report to the Director of services if the maintenance department does not respond quickly to requests.
See attachment A |
10/12/2016
| Implemented |
6400.112(a) | A fire drill was not conducted in May of 2016. | An unannounced fire drill shall be held at least once a month. | Penn-Mar¿s previous expectation was that Residential staff turn in fire drills on the first of the month for drills completed the prior month. This policy did not allow for enough oversight to ensure that drills were done each month. Therefore, all Residential Supervisors are now required to turn in fire drills by the 20th of each month. This will allow for a 10 day review so that Program Specialist can ensure that drills are done each month.
In additional, a monthly paperwork checklist was created that documents when fire drills are turned in and reviewed. Program Managers review this checklist monthly (near the end of the month) to ensure that the home they are monitoring has turned in drills for each month. This is documented on the monthly site monitoring.
See attachment E
Attached you will find that since May 2016, this home has completed monthly fire drills
See attachment F
All Residential Supervisors and Program Specialist level staff were trained on this new process so that we will not have a month in which a fire drill is missed again.
See attachment A |
11/26/2016
| Implemented |
6400.112(b) | There were 5 staff present during the 9/5/16 fire drill. There were 6 staff present during the 8/31/16 fire drill. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | Attached you will find October and November fire drills for Steltz road that show that one or two staff were present during the drill. This is the normal amount of staff who are scheduled for these days.
See attachment F
All Residential Supervisors and Program Specialist level staff were re-trained on the fact that fire drills should not be conducted during times when more staff are present in the home than the normal staffing schedule would allow.
See attachment A |
11/26/2016
| Implemented |
6400.112(d) | The 11/30/15 and 8/31/16 fire drill logs indicated evacuation times of 3 minutes and 41 seconds. The extended evacuation letter allowed a 3 minute and 30 second maximum evacuation time. | 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. | After further investigation into these drills that were not within the extended evacuation time frame, it was determined that staff were timing the drill until all individuals got to the meeting point instead of the time it took for all individuals to evacuate the home. Staff were re-trained on how to conduct fire drills. September, October and November drills were completed correctly and were within the evacuation time frame.
See attachment F
Penn-Mar¿s previous expectation was that Residential staff turn in fire drills on the first of the month for drills completed the prior month. This policy did not allow for enough oversight to ensure that fire drills were completed correctly and that all individuals evacuated within the required timeframe. Therefore, all Residential Supervisors are now required to turn in fire drills by the 20th of each month. This will allow for a 10 day review so that Program Specialist can ensure that drills are done correctly each month.
All Residential Supervisors and Program Specialist level staff were re-trained on how to conduct fire drills and specifically how the fire drill should be timed.
See attachment A |
11/26/2016
| Implemented |