| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.84 | The last fire safety inspection was completed on 03/05/19. The agency was closed due to COVID during the following dates: 3/17/2020-7/08/2020, 10/05/2020-10/19/2020 and 11/23/2020-2/08/2021 | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | The CEO will be responsible to ensure the onsite fire safety inspection is completed yearly. Documentation will have the signature of the fire safety inspector, the date it was completed and results from the inspection. This will be kept with the individual fire safety trainings. |
10/21/2021
| Implemented |
| 2380.115(2) | Emergency medical plan for individual #1 states, "if a person is unable to drive or seek medical attention, the agency will provide a vehicle so that the person maybe assessed by a physician of the medical facilities above"
This plan is ambiguous and does not indicate that 911 should be called, or who would be responsible for transporting the individual. | The facility shall have a written emergency medical plan listing the following: The method of transportation to be used. | CEO will be responsible for adding the method of transportation to all individual emergency medical plans. |
10/22/2021
| Implemented |
| 2380.115(3) | The emergency medical plan for individual #1 states that, "staff should ensure safety···". This does not constitute a completely constructed plan for the staff in the event of an emergency. Who should be notified? What staff are to stay at the facility? How many staff are to stay with the individual? Etc.
This plan should detail what responsibilities staff will have in the event of an emergency. | The facility shall have a written emergency medical plan listing the following: An emergency staffing plan. | CEO will be responsible for adding a staffing emergency plan to all individual emergency medical plans. |
10/22/2021
| Implemented |
| 2380.36(b) | Staff #3 had fire safety training on 8/17/2020 and not again until 10/12/2021. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The Agency Trainer will be responsible to ensure program specialists and direct service workers are trained annually by a fire safety expert on general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms and notification of the local fire department as soon as possible after a fire discovered. This training will be completed on or before their annual date. |
11/02/2021
| Implemented |
| Article X.1007 | Staff #2's Date of hire was 10/04/2021 but her criminal background check was not completed until 10/05/2021.
According to OAPSA regulations, criminal background checks must be completed on or before the employee's first day of work. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | The CEO will be responsible for the submission of the PA background check to the State Police for all prospective employees of the facility who have direct contact with individuals, 5 days prior to or on person's date of hire. |
11/02/2021
| Implemented |