| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Criminal history check was not completed prior to 2/2/20 date of hire for staff 1. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Criminal history checks will be filed in the employee's file timely. |
04/01/2020
| Implemented |
| 6400.77(b) | There was no antiseptic found in the first aid kit. | 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. | A check list will be created. The Administrative Assistant will check the kits monthly. The Admin assistant will compile the list of missing items and forward to the facilities coordinator, for ordering. |
04/01/2020
| Implemented |
| 6400.112(a) | There was no documentation of that an unannounced fire drill was held in the months of June 2019, December 2019, January 2020, and February 2020 . | An unannounced fire drill shall be held at least once a month. | The program Specialist and House Manager will ensure fire drills will be scheduled monthly to make sure that all fire drills are regularly conducted. The program specialist will track all monthly calendar in google to keep track of the unannounced drills |
04/01/2020
| Implemented |
| 6400.112(e) | There was no sleep drill held every six months. There was no sleep drill prior to 9/26/19 in the licensing year of 2019. | A fire drill shall be held during sleeping hours at least every 6 months. | The program Specialist and House Manger will ensure that an unannounced sleep drill occurs every six months. The program specialist will track all monthly drills through google calendars to ensure the dates are accurate |
04/01/2020
| Implemented |
| 6400.151(a) | Staff #1's record had no documentation of a physical exam, Tuberculin test, free from communicable disease and physical readiness. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Jami Residences Administrative Assistant will ensure that all physical examinations are current and entered into the employee's file timely, and to maintain for compliance |
04/01/2020
| Implemented |
| 6400.46(b) | Staff 2 was not trained annually in fire safety, there was no 2019 year training found in the record | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The agency has hired a training consultant, who will be responsible for providing all of Jami Residence staff training in accordance with OPD trainings requirements and will work to bring all of the organization employees training hours and requirements into compliance with ODP training regulatory requirements Person Centered and Incident Management |
06/30/2020
| Implemented |
| 6400.51(a)(1) | There was no record of orientation training for staff 1 prior to working with individuals and staff #1 date of hire is on 2/2/2020. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | The agency has hired a training consultant, who will be responsible for providing all of Jami Residence staff training in accordance with OPD trainings requirements and will work to bring all of the organization employees training hours and requirements into compliance with ODP training regulatory requirements Person Centered and Incident Management |
06/30/2020
| Implemented |