Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.21(a) | Staff 1's date of hire was November 1,2020. Staff 1 did not have a Pennsylvania State Police Criminal background check completed within 5 working days of hire. The Pennsylvania State Police Criminal background check was not completed until January 31, 2021. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | UCCH got her first individual on 8/17/2021, all focus was on this individual. UCCH completed FBI Fingerprint Check on staff. UCCH thought employees who does FBI Fingerprint clearance would not need to complete PA police criminal background check.
UCCH re-read the 6400 regulations and the agency policies regarding Criminal background checks with the assistance of the CEO, and all employees PA police criminal background check were completed on 1/31/2021. |
04/19/2021
| Implemented |
6400.112(d) | Individual 1 did not evacuate the home in 2.5 minutes or less as required during fire drills. During the November 11, 2020 fire drill, Individual 1 took 2 min 45 sec to evacuate the home; during the December 12, 2020 fire drill, Individual 1 took 3 minutes to evacuate the home; during the December 16, 2020 fire drill, Individual 1 refused to evacuate the home; December 20, 2020 fire drill, Individual 1 refused to evacuate after 3min 30sec. During the January 3, 2021 fire drill, Individual 1 took 3 min 20 sec. to evacuate the home; during the January 13, 2021 fire drill, Individual 1 refused to evacuate the home; during the January 19, 20201, Individual 1 took 3 minutes to evacuate the home; January 26, 2021 fire drill, Individual 1 took 3 minutes to evacuate the home. During all drills, verbal and physical prompts were utilized. Individual 1 has a desensitization plan to address his refusal to evacuate during fire drills. Individual 1 did evacuate the home during the allotted 2 min 30 sec on October 25, 2020, November 27, 2020 and February 15, 2021. | 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 employee 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. | UCCH behavioral specialist was able to develop a desensitization plan to address individual's refusal to evacuate his residence during fire drills. Staff go over educational plan developed by the BS, play fire safety videos to educate individual on the importance of fire drills. Individuals gets trained on this process weekly. In case of actual fire, fire department has been contacted and given appropriate information regarding the said Individual. Staff has also been trained on how to use his wheelchair for evacuation during an actual fire incase the individual refuses to evacuate. |
04/19/2021
| Implemented |
6400.15(b) | LII was completed on 8/31/2020 on an old document that does not include all components of the Chapter 6400 regulations. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The self assessment of the home has been completed on the current department's licensing inspection form. The program specialist made sure that the agency has the correct and current version of the Department's licensing inspection instrument and completes a self-assessment 3 to 6 months before the expiration date of the agency's COC. |
04/19/2021
| Implemented |
6400.32(r)(4) | Individual 1 has a lock on his bedroom door, however the lock can only be opened through a pinhole with a device such as a paperclip small enough to place in the pinhole. Individual 1 does not have the ability to unlock this type of lock from outside of his bedroom. This type of lock would not be able to be opened quickly in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The lock on the individual bedroom door has been changed to allow easy and immediate access by the individual and the staff person in case of an emergency. |
02/27/2021
| Implemented |
6400.34(a) | Individual 1 signed his rights statement on 10/25/20. Individual Rights have not been updated to reflect the current Chapter 6400 regulations. The missing rights include: 32k, 32p, 32q, 32s and 32t. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | UCCH has updated the individual rights to meet the 6400 regulations. The missing rights 32k, 32p,32q,32s and 32t has been included in order to be complaint and also have the home inform and explain the full individual rights to the individual.
The program specialist will be responsible to make sure that the individual rights meets all requirements in the 6400 regulations. The update individual rights has been read to the individual and signed for as well. |
04/19/2021
| Implemented |
6400.51(b)(3) | Staff 1 completed Individual Rights training on November 13, 2020 during her orientation training. Individual Rights have not been updated to reflect the current Chapter 6400 regulations. The missing rights include: 32k, 32p, 32q, 32s and 32t. | The orientation must encompass the following areas: Individual rights. | UCCH has updated the individual rights to meet the 6400 regulations. The missing rights 32k, 32p,32q,32s and 32t has been included in order to be complaint and also have the home inform and explain the full individual rights to the individual.
The program specialist will be responsible to make sure that the individual rights meets all requirements in the 6400 regulations. The program specialist will train the staff on Individual rights. |
04/19/2021
| Implemented |