| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The Agency did not complete Self-Assessment 3 to 6 months before the expiration of Certificate of Compliance 1/19/2019 | 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.
| We have created a tickler in our g-mail system to remind our QA team to conduct licensing self 'assessment on or before the October 30th of each year. The self-licensing self assessment would be spear-headed by the CEO annually. All management team members were retrained/discussed the 6400 licensing tool. |
02/28/2019
| Implemented |
| 6400.46(c) | The CEO only completed 12 hours of human services training in the 2018 training year. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | A tickler has been created in our newly subscribed training management software (Kaizen) to remind
the, CEO and training manager of required training and deadlines for completions. We are currently in negotiations with the College of Direct Support for subscription into their training models. As a backup, we also created a tickler in our google calendar to remind the CEO and training managers as well. Our quarterly QA review will look into compliance as well. |
02/28/2019
| Implemented |
| 6400.46(e) | The PROGRAM SPECIALIST STARTED ON 11/1/2018 AND Their RECORD DOES NOT INDICATE ID PLANNING, IMPLEMENTATION and TRAINING | Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | A tickler has been created in our newly subscribed training management software (Kaizen) to remind
the, CEO and training manager of required training and deadlines for completions. We are currently in negotiations with the College of Direct Support for subscription into their training models. The Program specialist has since been trained in all required training per 55 PA Code Chapter 6400.46(e). A tickler was set up in our google calendar to remind the program specialist, the CEO and training manager about required training as well. |
02/28/2019
| Implemented |
| 6400.46(f) | THE PROGRAM SPECAILIST'S RECORD DOES NOT INDICATE INITAL FIRE SAFTY TRAINING WITHIN 30 DAYS OF WORKNIG WITH INDIVIDUALS. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | A tickler has been created in our newly subscribed training management software (Kaizen) to remind
the, CEO and training manager of required trainings and deadlines for completions. We are currently in negotiations with the College of Direct Support for subscription into their training modules. The program specialist and CEO are working with the local fire department to be enrolled in the next class, a date not yet determined. |
02/28/2019
| Implemented |
| 6400.67(a) | The fabric on the chair was peeling off the surface during inspection | Floors, walls, ceilings and other surfaces shall be in good repair. | The chair has since been replaced. Our quarterly QA inspection would look for damaged/worn out furniture and ensure they are replaced within 10 days of the discovery. Managers are also instructed to put in requisitions to replace/repair torn furniture/fittings. |
02/28/2019
| Implemented |
| 6400.67(a) | The fabric on the sofa was ripped. | Floors, walls, ceilings and other surfaces shall be in good repair. | The chair has since been repaired. Our quarterly QA inspections would look for damaged/worn out furniture and ensure they are replaced/repaired within 10 days of the discovery. Managers are also instructed to put in requisitions to replace/repair torn furniture/fittings immediately upon discovery. |
02/23/2019
| Implemented |
| 6400.77(b) | The first Aid kit did not have tweezers during the inspection. | 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. | The first aid kit has since been completed with tweezers. Going forward, house manager, program specialist, and Agency nurse would be required to use the licensing tool 55 PA code chapter 6400.77(b) as a guide when replacing or replenishing first aid kits. All managers and leadership team retrained/discussed licensing tool. |
02/28/2019
| Implemented |
| 6400.82(f) | There was no paper towel or cloth towel 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. | The individual is not toilet trained and uses Depends pull-ups due to incontinence issues. He is wiped/cleaned on his bed using adult wipes. However, we have since furnished the bathroom with paper towel. Going forward, house manager would ensure the bath room has paper towel times. Our quarterly QA/self licensing team will look for compliance with 55 PA code 6400.82(f). |
02/28/2019
| Implemented |
| 6400.168(a) | The CEO confirmed that staff person# 3 is giving individuals medications. Staff person#3's record indicates they did not complete the last Medication Observation | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Staff #3 has since been observed for her last meds administration. Going forward, the Agency nurse would check all newly trained medication administrator's records, for PA code chapter 6400.168(a) compliance, give her/his okay before the staff can pass medication. Our quarterly QA process would look for compliance as well. |
02/28/2019
| Implemented |
| 6400.168(a) | The CEO confirmed that staff person# 2 is giving individuals medications. Staff person#2's record indicates they did not complete the last two Medication Observation. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Staff #2 has since been observed for her last two meds administration. Going forward, the Agency nurse would check all newly trained medication administrator's records, for PA code chapter 6400.168(a) compliance, give her/his okay before the staff can pass medication. Our quarterly QA process would look for compliance as well. |
02/28/2019
| Implemented |