| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no indication that a self-assessment was completed for 107 Bob White Lane due to the self-assessment forms not containing a residential home address for which home an assessment was completed on. The legal entity address was recorded on all self-assessment forms. | 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.
| 1. The CEO trained Vice President on regulation 6400.15A on 09/04/2018 to have addresses properly identified on the self-assessment.
2. All other locations were not in compliance with this regulation. This violation was addressed by the licensor on 08/29/2018 during on-site inspection.
3. The President and Vice President and house team leads were trained on regulation 6400.15A by the CEO to ensure that all self-assessments will have the proper addresses listed with reference to Regulation 6400.15A. The President, Vice-President and House Team Leads will sign off on signature paper by 12/31/2018.
4. The CEO will review with the Vice President the self- assessments on a yearly basis to ensure compliance. |
10/12/2018
| Implemented |
| 6400.62(a) | All cleaning supplies, approximately 10+ bottles, that contain labels to contact poison control center were left unlocked and accessible in the staff office. The first aid kit contained antiseptics that indicated to contact the poison control center, and this was found unlocked and accessible sitting on the refrigerator in the kitchen. The individual living at the home was assessed to not be safe around poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1.During licensing on 08/30/2018, the office door was locked by program specialist after violation 6400.62a was noticed.
2. On 09/04/2018, the quality compliance manager checked all other homes that were not reviewed by the state licensor. All other houses outside of homes that were not reviewed by state licensor were found in compliance.
3. All staff will be trained on regulation 6400.62a by Program Specialist to ensure that all staff are following the restrictive plan as written. Staff will sign off on training signature paper by 12/31/2018.
4. The Program Specialist on a monthly basis will review with all staff to ensure compliance with this regulation starting on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.74 | The wooden, basement steps were not equipped with non-skid surfaces. There were approximately 15 steps. | Interior stairs and outside steps shall have a nonskid surface.
| 1. It is important to have non-skid surfaces on interior and exterior steps to help assure the safety of
individuals. On 9/08/2018, non-skid strips were added basement steps.
2. On 09/04/2018 the quality compliance manager reviewed all other house locations to make sure
that all interior and exterior steps have non-skid surfaces. All other locations were in compliance
with this regulation.
3. All staff will be trained by the licensed compliance manager on regulation 6400.74 to ensure that
all interior and exterior steps have non-skid surface. Staff will sign off on training signature paper
by 12/31/2018.
4. On 11/01/2018, quality compliance manager will check on a weekly basis that all interior and
exterior steps to have non-skid strips for all houses. |
10/12/2018
| Implemented |
| 6400.77(c) | The first aid kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | 1. Fixed on site on 08/30/2018 there was an additional first aid kit at the home in which manual was placed in the first aid kit that was inspected.
2. On 09/04/2018, quality compliance manager checked all other first aid kits in the other homes. All other first aid kids were in compliance with regulation 6400.77c.
3. All staff will be trained on regulation 6400.77c by quality compliance manager to ensure that all contents are in the first aid kit. Staff will sign off on training signature page by 12/31/2018.
4. Starting on 11/01/2018 during the monthly fire drill, all first aid kits will be checked to make sure that all correct items are in the first aid kit. |
10/12/2018
| Implemented |
| 6400.104 | A notification letter sent to the fire department on 5/23/18 indicated that Individual #1 lived at 194 Paradise Rd, Mineral Point, PA. However Individual #1 currently lives at 107 Bob White Lane, Mineral Point PA. The notification letter also indicated Individual #1 was independent with evacuation however the fire drills from May 2018 to July 2018 indicated Individual #1 required assistance to evacuate during fire drills. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| 1. The program specialist updated the letter to the fire department immediately. The new fire drill letter was resubmitted to the Nanty Glo fire dept on 8/31/18.
2. The program specialist reviewed all other fire drill letters for correctness of the address. This was completed on 08/31/2018. It was found that all other locations were in compliance.
3. All staff will be trained on regulation 6400.104 by the program specialist to ensure that correct address is on fire drill letter that is sent to the fire company. Staff will sign off on training signature page by 12/31/2018.
4. The CEO will review all individual¿s fire safety letters on a quarterly basis to ensure compliance with the CEO review signature sheet starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.110(a) | The smoke detector in the basement did not sound. The attic was kept shut with a padlock and a smoke detector is not located in the attic. The agency has the key to the attic thus granting them access to the attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 1. On 8-30-18 NSC maintenance installed an interconnected smoke detector in the basement.
2. The quality compliance manager checked all other locations to make sure that all interconnected smoke detectors work. This was completed on 09/04/2018. It was found that all other locations were in compliance.
3. All staff will be trained on regulation 6400.110a by the fire safety expert to make sure that there is always one interconnected smoke detector on each floor. Staff will sign off on training signature paper by 12/31/2018.
4. Immediately and continuing every month, all smoke detectors shall be checked by a designated staff person who is trained in the use of smoke detectors and fire alarms to ensure that there is at least one operable automatic smoke detector on each floor of all community homes. |
10/12/2018
| Implemented |
| 6400.111(a) | The attic was kept shut with a padlock and a fire extinguisher is not located in the attic. The agency has the key to the attic thus granting them access to the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 1. On 08/30/2018 the President turned back in the attic keys to the landlord, so no one has access to the attic.
2. On 09/04/2018 the Quality Compliance Manager checked all other homes that was not cited for 6400.111.a and found all other homes to be in compliance.
3. All staff will be trained on Regulation 6400.111.a to include that all floors will have a minimum of 2-a rating fire extinguisher. Staff will sign off on signature page by 12/31/2018.
4. The quality compliance manager will check on a weekly basis to ensure that there is at least one fire extinguisher with a 2-a rating on each floor in all individual homes. The quality compliance manager will sign off on checklist to ensure compliance with this regulation starting on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.113(a) | There was no indication that Individual #1 received fire safety training in 2018 by his/her date of admission to the facility due to an illegible signature on the fire safety training form. The agency did not indicate the name of the individual who received fire safety training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | 1. The Program Specialist went back and printed the individuals name on 09/04/2018 to go along with the individual¿s initials and or signature that was illegible. The Fire Safety Expert will sign off on all of the individual¿s fire safety training to make sure that the individuals are getting trained correctly.
2. The Program Specialist reviewed all other fire safety trainings and made corrections and clearly identified the individuals were trained in fire safety on 09/04/2018 to 09/06/2018.
3. All staff will be trained on regulation 6400.113A by the Fire Safety Expert to make sure that all individuals are properly trained in fire safety with reference to Fire Safety Training-Training outline, staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all individual¿s fire safety on a quarterly basis to ensure compliance with the CEO review signature sheet starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.195(a) | The residential home had all eating utensils, forks, spoons and knives, stored in the office cabinet that is kept locked due to locking the office door. There were also 5-6 bags of snacks that are always stored in this cabinet that are kept locked from the Individual #1. Individual #1 who lives in the home, did not have a restrictive plan in place to lock up all eating utensils or food. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| 1. The Program Specialist contacted staff on shift at the house and staff communicated that the snacks that were locked up with their snacks. This was done on 08/30/2018. The Program Specialist reviewed restrictive plan on individual which stated that all sharps were to be locked up on 08/30/2018.
2. The Program Specialist identified what sharps that will be locked up within a restrictive plan at all locations. The restrictive plan will be reviewed by human rights committee as needed to make any changes to the restrictions. The staff were notified on all snacks that they bring into the group home and will label their own snacks and the snacks will be put in the office of the group home on 08/30/2018.
3. All staff will be trained on regulation 6400.195a by the program specialist with reference to snacks being locked up and labeled. Staff will sign off on training signature paper by 12/31/2018.
4. The Program Specialist will review Regulation 6400.195a with all staff on a semi-annual basis starting 12/31/2018. |
10/12/2018
| Implemented |
| 6400.216(a) | Individual records were unlocked and accessible in the staff office. When the physical site inspection was conducted 8/31/18, the staff office was not locked prior to the last staff's departure from the home. | An individual's records shall be kept locked when unattended.
| 1. During licensing on 08/30/2018, the office door was locked by program specialist after violation 6400.216a was noticed.
2. It is important that an individual¿s record is kept locked to assure their privacy. This violation occurred because the staff on duty did not lock the office door. This was an oversight by the staff on duty at the time. Staff that were on duty were notified on 08/30/2018 that they left the office door unlocked and that this was a violation of the 6400.216a.
3. All staff will be trained by 12/31/2018 on regulation 6400.216a with reference to Privacy of the Individuals by the Program Specialist. Staff will sign off on training signature paper by 12/31/2018.
4. The Licensing Compliance Officer will review this on a semi-annual basis with all staff starting 12/31/2018 |
10/12/2018
| Implemented |