Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.21(a) | A criminal background check was not completed for volunteer staff #1, whom works as a direct care staff having direct contact with individuals. The provider did not conduct a background check for this person as their understanding of the regulations was that it was not necessary if the person is a volunteer. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes 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. | A PA criminal background check was obtained for the subject volunteer staff as of 03/22/2022. Please see attachment attachment #1. |
03/22/2022
| Implemented |
6400.65 | The bathroom located on the second floor did not have window or a operable mechanical ventilation. The existing skylight could not be opened at the time of inspection. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| An opening was made in the skylight screen to enable access to the operating chain, which is used to control the mechanical ventilation on 03/14/2022. Please see attachment #2. |
03/14/2022
| Implemented |
6400.72(b) | The screen door located in the basement was damaged and could not be closed. | Screens, windows and doors shall be in good repair. | The faulty screen door was removed on 03/14/2022. Please see attachment #3. |
03/14/2022
| Implemented |
6400.111(f) | The Fire Extinguisher located in the basement was not properly inspected as it had a pass due inspection label with a current inspection year written in marker. Provider stated that the inspection company ran out of current labels and hand wrote the current inspection date over an expired inspection tag. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | This particular fire extinguisher was re-tagged by the Fire safety company on 03/31/2022. Please see attachment #4. |
03/31/2022
| Implemented |