| 6400.15(c) | The self-assessment that was completed for 40 South Penryn Road Manheim, Pa 17545 dated 8/25/23-9/13/23 indicated violations for regulation 165b, and 181f, but did not have an attached summary of correction.
Self-assessment begin date of 1/24/2023 and end date of 2/28/2023 lists citations for 165b and 181f. There is no written summary of correction made available for these two violations. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| - The Director of Residential Services provided verbal and written education/retraining to Program Specialists on 10-23-23 regarding regulation 15C that specifies the summary of corrections and attached proof that the plan of correction is completed with the self-assessments.
- Director of Residential Services met with the Instructional Technology department on 9-25-23 regarding the syncing issues of the agency's drive that maintains the summary of corrections and assessments.
- The Director of Residential uploaded the plan of corrections for the Penryn Home on 10-13-23. |
10/30/2023
| Implemented |
| 6400.112(c) | The fire drill held on 8/7/23 stated the hypothetical fire location was the downstairs living room, but the exit route used was out the front door, which can only be accessed through the living room. This is counterproductive because the idea is to lead individuals to a safe evacuation route away from the fire location.
The fire drill held on 5/24/2023 does not indicate the hypothetical location of the fire. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Management and Direct care staff were all retrained on this regulation by Director of Residential Services Leo Marcantonis on 10-5-23. The residential management will be further retrained on this regulation in an in-person training on October 25th. Training includes that the fire drill must always state what the hypothetical location of the fire is and that the smoke detector that is closest to the hypothetical location of the fire should be the smoke detector that is used. |
10/13/2023
| Implemented |