| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | No indication if Staff #1 or Staff #2 have resided in the COPA for the past 2 consecutive years. | If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. | On July 21, 2021 an email was sent to our advertising firm to add the following statement to our application forms. "I affirm that I have been a resident of the Commonwealth of Pennsylvania for the past two (2) years, from the date of my application for employment with Royer-Greaves School for Blind". Please find attached a copy of the email and the updated application labeled Item #18 |
07/21/2021
| Implemented |
| 6400.62(a) | Poisonous material such as (paint, paint thinner, cleaning supplies, Clorox) were all in an unlocked closet located in the basement. | Poisonous materials shall be kept locked or made inaccessible to individuals. | A lock was placed on the closet door in the basement on 9/22/2021. Please see attached copy of photo of lock on door labeled Item #20. |
09/21/2021
| Implemented |
| 6400.112(d) | The fire evacuation time for 5440 Chichester Avenue exceeded the 2 ½ minutes on 5/1/21, the time was 4min 56 min. No other drill was conducted. | 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. | Fire drills will be reviewed by House Supervisor and any discrepancies detected will be reported to the Deputy Executive Director. |
09/21/2021
| Implemented |
| 6400.112(e) | A sleeping fire drill was not held every 6 months for the homes: Chichester Ave. | A fire drill shall be held during sleeping hours at least every 6 months. | A sleeping fire drill was done on 7/28/2021. Please see copy of attached fire drill labeled #21 |
09/21/2021
| Implemented |
| 6400.113(a) | Fire safety training for Individual #6 is dated 3/24/21. Fire safety training is to be completed prior to or at time of admission. Individual #6's DOA is 7/13/2020. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Fire safety training was added to the pre-admission package for all Individuals. Please see attached list labeled Item #22 |
09/21/2021
| Implemented |
| 6400.151(a) | Physicals for Staff #5 exceeded 2 years. Previous physical was on 9/11/18 and most recent physical was on 6/12/21. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | When an employee is out of compliance with submitting a physical in a timely manner the employee will be taken off the schedule and will not return to work until the physical has been received. Please see copy of memo and letter to employee labeled Item #23. |
07/27/2021
| Implemented |
| 6400.181(a) | No initial assessment for Individual #6. The only assessment on file is dated 1/28/21, which is more than 6 months after their admission date of 7/13/2020. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | This expectation was reviewed with the program specialist to ensure that all needed documentation will be completed in a timely manner. |
09/22/2021
| Implemented |
| 6400.217 | No consent for information released for Individual #6. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Copies of consent was emailed to the family on 2/22/2021, on March 9. 2021 another email reminder was sent, then again on May 26, 2021 a reminder email was sent and June 1, 2021. Telephone phones were also made requesting the signed consents. Individual #6. Family refused to return the signed consents. Attached please find copies of those emails labeled Item #24 |
09/14/2021
| Implemented |
| 6400.31(b) | No signed copy of Individual #6's rights. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Copies of consent was emailed to the family was sent on 2/22/2021, on March 9. 2021 another email reminder was sent, then again on May 26, 2021 a reminder email was sent and June 1, 2021. Telephone phones were also made requesting the signed consents. Individual #6 Family refused the return the signed consents. Attached please find copies of those emails labeled Item |
09/14/2021
| Implemented |
| 6400.46(d) | Staff #3- hire date 12/15/20, did not receive First Aid/CPR certification until 7/6/21 (more than 6 months after date of hire) | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Because of the Covid- 19 pandemic and fear of transmission all trainings were suspended resulting in some training being completed late. |
09/21/2021
| Implemented |