| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The basement floor had puddling of water throughout the basement and the 3 x 4 foot drain was overflowing with water. | Floors, walls, ceilings and other surfaces shall be in good repair. | o This regulation is important because of health and safety issues. Wet/flooded basement can put the individuals' health at risk
o The basement floor had puddling of water throughout the basement and the 3 x 4 foot drain was overflowing with water
o Front Gutter of the home was block due to overgrowth mini tree. Causing the prevention of the free floor of the rain water. Which then forced the flow of water in the basement
o The basement floor was immediately cleaned to resolve the violation. In addition, the tree was cut, and the gutter was cleaned
o Ensuring that the gutter is clean of all tree leaves, ensuring that no trees are planted near the gutter's exit point will be used to prevent future flooding of the basement
o CEO, Douglas Jones, will monitor the home gutter exit point, including the gutter to ensure no blockages. The gutter will be clean at least once a year.
o Acute anticipated the resolution of this violation by 6/27/19
o Violation was resolved on 6/27/19
o Based on analysis of other homes, there are no similar violations |
06/27/2019
| Implemented |
| 6400.72(b) | The slat is missing from the kitchen mini blinds | Screens, windows and doors shall be in good repair. | o This regulation is critical as it promotes privacy in the individual's room
o There are several slats that are broken in the mini blinds located in Individual # 1 bedroom
o Due to consistently pulling of the blinds by one of the individuals we serve, one string was broken/removed.
o To resolve this violation, the blinds were replaced with window curtains. Allowing for consistent privacy
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor the blinds and window curtains of the home and ensure they are in acceptable conditions and not broken/missing. To prevent future violations, the Lead Staff must conduct a daily check.
o Violation was estimated to be corrected by 6/21/19
o Violation was completed by 6/21/19
o Based on analysis of other homes, there are no similar violations |
06/21/2019
| Implemented |
| 6400.72(b) | There are several slats that are broken in the mini blinds located in Individual # 1 bedroom | Screens, windows and doors shall be in good repair. | o This regulation is critical as it promotes privacy in the individual's room
o There are several slats that are broken in the mini blinds located in Individual # 1 bedroom
o Due to consistently pulling of the blinds by one of the individuals we serve, one string was broken/removed.
o To resolve this violation, the blinds were replaced with window curtains. Allowing for consistent privacy
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor the blinds and window curtains of the home and ensure they are in acceptable conditions and not broken/missing. To prevent future violations, the Lead Staff must conduct a daily check.
o Violation was estimated to be corrected by 6/21/19
o Violation was completed by 6/21/19
o Based on analysis of other homes, there are no similar violations |
06/21/2019
| Implemented |
| 6400.76(a) | There was a golf ball size lint in the dryer during inspection. | Furniture and equipment shall be nonhazardous, clean and sturdy. | o This regulation is critical as it prevents fire. Leaving lint in the dryer may cause fire
o There was a golf ball size of lint in the dryer during inspection.
o Staff did not insure that he dryer lint was clean after drying the individual clothes
o Staff immediately clean the dryer lint to fix the violation
o To prevent future violation, staff was trained to properly clean the dryer lint from the dryer. This was done through demonstrations.
o Lead Staff of the home, Linda Monroe, will monitor the dyer to insure the lint is removed consistently. This will be done through random visits and engaging staff on a consistent basis. A datasheet will be created in the long term if need be.
o Acute anticipated the resolution of this violation by 6/21/19
o Violation was resolved on 6/21/19
o Based on analysis of other homes, 217 Westbridge had similar violation and it was resolved
o Training was completed on 7/11/19 |
06/21/2019
| Implemented |
| 6400.76(a) | The right side of the living room couch was worn and springs are sunken in during inspection. | Furniture and equipment shall be nonhazardous, clean and sturdy. | o Regulation is critical because it put forward the home of the individuals as presentable and habitable
o The right side of the living room couch was worn and springs are sunken in during inspection.
o One of our individual consistently hops in the chair, causing the chair spring to weaken
o The chair was immediately replaced with a new one.
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor the condition of the living room chair to ensure all living room chairs are in good condition and report any damages.
o Acute anticipated the resolution of this violation by 6/29/19
o Violation was resolved on 6/29/19
o Based on analysis of other homes, there are no similar violations |
06/29/2019
| Implemented |
| 6400.76(a) | Two of the three dining room chairs was heavily stained and one chair had one of the supports missing from the back of the chair. | Furniture and equipment shall be nonhazardous, clean and sturdy. | o Regulation is critical because it puts forward the home of the individuals as presentable and habitable
o Two of the three dining room chairs was heavily stained, and one chair had one of the supports missing from the back of the chair.
o The chairs were immediately replaced with 4 new chairs.
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor the condition of the dining room chair to ensure all dining room chairs are in good condition and report any damages. The chairs were replaced with stain resistant chair to prevent future violation
o Acute anticipated the resolution of this violation by 6/29/19
o Violation was resolved on 6/29/19
o Based on analysis of other homes, there are no similar violations |
06/29/2019
| Implemented |
| 6400.82(f) | The Bathroom did not have towels or paper towels. | 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. | o This regulation is critical as it promotes proper hygiene
o The Bathroom did not have towels or paper towels
o Paper towels are consistently misused and forced in the toilet by one of the individuals we served, prompting the shortage of paper towel in the bathroom and also clog the toilet
o To resolve this violation, hand towels were immediately purchased and placed in the bathroom for use
o Staff was trained on the importance of ensuring that either paper towel or towel is always present in the bathroom. Staff will consistently community the need to towel/paper towel in the bathroom
o Lead Staff of the home, Linda Monroe, will ensure that staffs are utilizing the training put forward to validate the present of towels
o Violation was estimated to be corrected by 6/21/19
o Violation was completed by 6/21/19
o Based on analysis, location 217 Westbridge Glenolden PA has similar violation but was corrected |
06/21/2019
| Implemented |
| 6400.83(c) | The kitchen cabinets had two plates, two bowls, 3 forks and 5 spoons for all the individuals living in the home. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | o o This regulation is very important to the individuals as it promotes Every Day Lives
o The kitchen cabinets had two plates, two bowls, 3 forks and 5 spoons for all the individuals living in the home.
o Existing dishes and bows were damaged by one of the individuals and parents requested that disposable dishes be utilized.
o New bows (set of 8), New dinning plates (set of 8), new desert plates (set of 8), spoons (set of 8) and folks (set of 8) were immediately purchased.
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor the dishes and plates in the home to ensure that at least 8 pieces of each kitchen items are available in the home.
o Acute anticipated the resolution of this violation by 6/24/19
o Violation was resolved on 6/24/19
o Based on analysis of other homes, there are no similar violations |
06/24/2019
| Implemented |