| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a golf ball size of lint in the lint trap. | Clean and sanitary conditions shall be maintained in the home. | 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 lint trap
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, 611 Glencroft Circle Folcroft PA had similar violation and it was resolved
o Training was completed on 7/11/19
o Based on analysis, location 611 Glencroft Circle Folcroft PA has similar violation but was corrected |
06/21/2019
| Implemented |
| 6400.64(a) | The entire carpet in Individual #1 bedroom is dirty and stained. | Clean and sanitary conditions shall be maintained in the home. | o This regulation is critical as it could be a health hazard
o The entire carpet in Individual #1 bedroom is dirty and stained.
o Individual consistently spill soda, coffee and any beverage to express her anger or when in an aggressive state.
o To resolve the violation, the carpet was removed, and the hardwood floor was cleaned. This will allow for mopping the floor whenever beverages are spilled.
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor the home, including all room and surfaces to ensure a stain free environment. Lead staff will conduct a weekly check.
o Acute anticipated the resolution of this violation by 7/1/19
o Violation was resolved on 7/1/19
o Based on analysis of other homes, there are no similar violations |
07/01/2019
| Implemented |
| 6400.66 | The rear exit did not have light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| o This is regulation is important for safety purposes. Individual utilizing the back exit of the home must have a visible path, especially during the night
o The rear exit did not have light.
o After purchasing the home, it was not noticed that the rear of the building did not have light in the back.
o A new outdoor light was immediately installed to resolve the violation
o To prevent future violation, each new home purchased will be fully inspected for rare lighting.
o CEO, Douglas Jones, will monitor each external lighting at the home and ensure they are functional. There will be a weekly inquiry done through on duty staff.
o Acute anticipated the resolution of this violation by 7/1/19
o Violation was resolved on 7/1/19
o Based on analysis of other homes, there are no similar violations |
07/01/2019
| Implemented |
| 6400.72(a) | The front screen door does not close and needs repair. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | o This regulation is critical due to hazard and presentation
o The front screen door does not close and needs repair
o Individual repeatedly breaks the storm screen door when expressing frustration or anger
o A new storm screen door was immediately installed
o Staff was trained on timely reporting of damaged properties in the home. In the long term, behavior specialist will be working closely with the psychiatrist to determine the underlining root cause of behaviors
o Lead Staff of the home, Linda Monroe, will continue to conduct frequent monitoring of the door to ensure damages are report timely. Staffs will also report timely damages
o Acute anticipated the resolution of this violation by 6/28/19
o Violation was resolved on 6/28/19
o Based on analysis of other homes, there are no similar violations |
06/28/2019
| Implemented |
| 6400.76(a) | The Ceiling fan in the dining room is detached from the base. | Furniture and equipment shall be nonhazardous, clean and sturdy. | o This regulation is critical for safety and presentation purposes
o The Ceiling fan in the dining room is detached from the base
o Due to the constant pulling of the ceiling fan rope, the ceiling fan cap got loose, causing some exposure of wirings.
o The ceiling fan cap was immediately screwed, securing all wiring.
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor all ceiling fans in the home. Lead staff Linda Monroe will continue to conduct follow ups with staffs to endure all ceiling fan lights are in working conditions.
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, there are no similar violations |
06/21/2019
| Implemented |
| 6400.76(a) | Individual # 1 bedroom curtain rod was bent and attached to the window. | Furniture and equipment shall be nonhazardous, clean and sturdy. | o This regulation is critical for privacy purposes
o Individual # 1-bedroom curtain rod was bent and attached to the window
o Individual consistently pulls down and sometimes breaks the curtain rod in expressing her aggression
o A new curtain rod was immediately purchased and installed
o Staff was trained on timely reporting of damaged properties in the home
o Lead Staff of the home, Linda Monroe, will monitor all curtain rods in the home. Lead staff Linda Monroe will continue to conduct follow ups with staffs to endure all rods are properly placed and are in functioning conditions.
o Acute anticipated the resolution of this violation by 6/28/19
o Violation was resolved on 6/28/19
o Based on analysis of other homes, there are no similar violations |
06/28/2019
| 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 was present in the home but was not in the basement bathroom.
o To resolve this violation, paper towel was immediately 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. Lead staff will conduct a random check.
o Violation was estimated to be corrected by 6/21/19
o Violation was completed by 6/21/19
o Based on analysis, location 611 Glencroft Circle Folcroft PA has similar violation but was corrected |
06/21/2019
| Implemented |
| 6400.83(c) | There was only one plate and bowl in the kitchen for the individual to use. | 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 |
| 6400.110(e) | The smoke detectors in the basement, main floor, and second floor were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | o This regulation is important as it saves lives.
o The smoke detectors in the basement, main floor, and second floor were not interconnected.
o Wrong smoke detector was installed during the initial purchase of the home and were installed on each level of the home. Because the home is a 3-story home, each smoke detector must interconnect.
o New interconnected smoke detectors were installed
o To prevent future violation, each replacement smoke detector will be of the interconnected technology
o Douglas Jones, CEO, will ensure the appropriate interconnected smoke detector is supply whenever there is a need for replacement.
o Acute anticipated the resolution of this violation by 6/30/19
o Violation was resolved on 6/28/19
o Based on analysis of other homes, there are no similar violations |
06/28/2019
| Implemented |