| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.61(b) | The consumer's bed was found in the dining room area due to staff stating that the individual could not handle stairs due to mobility issues. A review of the ISP indicates the individual with some assistance can navigate stairs and live in the upstairs bedroom area. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home. | SHT can ambulate independently without assistance. Provider will take responsible action to remove the bed from the dinning area and remain in compliance with the regulation - 55 PA Code Chapter 6400.61(b) Moving forward when SHT returned from dialysis and other doctors appointments, staff will prompt her to go upstairs to her bedroom to get some rest as needed. The Program Specialist is responsible for this action. Provide will complete by 1/31/2021. |
01/31/2021
| Implemented |
| 6400.64(f) | Trash was found outside on the grounds. The outside trash can did not have a lid' | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Commonwealth will follow the guideline according to 55 PA Code Chapter 6400.64(f), and will purchase a new Trash Can with a lid to ensure the prevention of insects and rodents from accessing the trash. The Residential Manager will be responsible to implement this function. |
01/31/2021
| Implemented |
| 6400.65 | No ventilation was found in the bathroom. The skylight chain used to open or close the window was found to be missing. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Commonwealth Supportive Services will install a new ventilation system within the bathroom to promote adequate ventilation in the area according to 55 Pa Code Chapter 6400.65. The Executive Director will be responsible for this action. |
01/31/2021
| Implemented |
| 6400.67(a) | The basement ceiling was found cracked along its length. | Floors, walls, ceilings and other surfaces shall be in good repair. | Commonwealth will take responsible action to repair the crakes in the basement ceiling to be in compliance according to 55 PA Code Chapter 6400.67 (a) and will always ensure all ceilings are in good maintenance condition moving forward. the Executive Director will ensure this responsibility is implemented. |
01/08/2021
| Implemented |
| 6400.70 | The cordless phone was not located on its base and it was not found during inspection. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Commonwealth will replace the cordless phone with a line phone within the consumer's home, that will be easily and readily accessible to the consumer and staff, to remain in compliance according to 55 PA Code Chapter 6400.70 The Executive Director will implement this action. |
01/31/2021
| Implemented |
| 6400.72(b) | The consumer's bedroom screen was found ripped. | Screens, windows and doors shall be in good repair. | Commonwealth will ensure all consumers bedroom window screens are in good condition in accordance with 55 PA Code Chapter 6400.72(b). The Residential Manager is responsible for the ongoing maintenance of the physical sites. |
01/31/2021
| Implemented |
| 6400.77(b) | No thermometer was found in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Commonwealth will ensure that the site have a fully equipped First Aid kit with all necessary items including a thermometer in accordance with 55 PA Code Chapter 6400.77(b). The Residential Manager will be responsible to make sure nothing is missing from the First Kit. |
01/31/2021
| Implemented |
| 6400.82(c) | There was a bucket and a wooden chair found in the tub. Staff reported that the bucket is used to bath the consumer due to her immobility. | (c) For homes serving one or more individuals who have physical disabilities, at least one sink, one toilet and one tub or shower shall be adapted so that individuals who have physical disabilities have easy access and use.
| SHT is able to ambulate independently and does not have mobility issues. Provider will install a grab bar in the bathtub and a shower chair for added safety and ease in accordance with 55 PA Chapter 6400.82(c) The Executive Director is responsible to make this happen. |
01/31/2021
| Implemented |
| 6400.82(f) | No toilet paper was found in the bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Commonwealth will ensure that the bathrooms in all its sites will always have paper towels at all times , to be in compliance with 55 PA Chapter 6400.82(f) The Residential Manager will be responsible to ensure toilet supplies including toilet papers are available at all times in consumers bathrooms. |
01/31/2021
| Implemented |
| 6400.111(a) | There were no fire extinguishers found in the basement or the third floor level, | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Commonwealth will place a fire extinguisher in the basement and on every floor of the building in accordance with 55 PA Code Chapter 6400.111(a) The Executive Director will be responsible for this function. |
01/31/2021
| Implemented |