| 6400.15(a) | The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15. | 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.
| WHO: Douglas Jones, CEO/Administrator
WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15.
WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16
HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments.
PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter.
An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office.
ATTACHMENT AND SUPPORTING DOCUMENTS
Self-Assessment
WHO: Douglas Jones, CEO/Administrator
WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15.
WHEN: Target Date of completion was 05/04/16. Specific Date of Completion was 05/04/16
HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments.
PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter.
An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office.
ATTACHMENT AND SUPPORTING DOCUMENTS
Self-Assessment
WHO: Douglas Jones, CEO/Administrator
WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15.
WHEN: Target Date of completion was 05/07/16. Specific Date of Completion was 05/07/16
HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments.
PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter.
An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office.
ATTACHMENT AND SUPPORTING DOCUMENTS
Self-Assessment
|
05/07/2016
| Implemented |