| 6400.15(a) | The self-assessment did not include a date of completion; therefore, compliance could not be measured. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| To correct the deficiency for 55 PA Code Chapter 6400.15(a) after LiL is completed the team Lead and the supervisor together will review LiL for blanks to assure every line is completed. After it is submitted to the Senior Manager it will be reviewed again for completion. [Within 30 days of receipt of the plan of correction, a designated management staff person shall educate the aforementioned staff persons of the aforementioned procedures to ensure self-assessments are fully completed including date of completion with in the required timeframe. Documentation of training shall be kept. Documentation of aforementioned reviews of the self-assessments shall be kept. (AS 4/11/18)] |
04/10/2018
| Implemented |