|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not fully complete the self-assessment, dated 3/9/2020, to measure and record compliance with each regulation for Title 55 Pa. Code Chapter 6400. The sections, to record if each regulation was either compliant, a violation, not applicable or not measured, were left blank. | 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.
| On February 1, 2021, (Program Specialist) complete the self assessment. Program Specialist will make sure that a self-assessment for each site is completed 3-6 months prior to on site inspection. CEO will audit assessment to assure the assessment is complete and all correction are made to assure compliance and assure that the same violation do not reoccur in the future. The POC will be implemented as of February 1, 2021. Upon receipt of certificate of compliance, the CEO or designee shall develop and implement a tracking system to ensure the self-assessment is completed timely. Prior to 3 months of the expiration date of the current certificate of compliance the CEO shall audit all completed self-assessment to ensure completion, timely. Documentation of audits shall be kept. [On 2/22/21, copies of the completed self-assessment and "physical site checklist", signed by the PS on 1/31/21 and CEO on 2/1/21 was provided to the Department. (AES,HSLS on 2/23/21)] |
02/01/2021
| Implemented |
| 6400.63(a) | On 1/21/2021 at 10:57AM, the hot water temperature in the sink in the bathroom in the hallway of the home measured 124°F. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | On February 3, 2021, a regulator was place by certified plumber to meet requirements as per 6400.63. The water temperature was taking 3 times and did not exceed 120. The last temperature was taken read 108 F. The program specialist immediately checked all water tempers in the homes to ensure compliance. All anti-scald protective devices will be checked for functionally upon installation and monthly thereafter. The Program Specialist will audit monthly all water temperatures and functionally to ensure safety. The CEO or designee shall educate all staff to the aforementioned procedures.[On 2/22/21, a copy of the hot water temperature log was provided to the Department showing water temperatures on 2/2/21 at 117F, 2/3/21 at 108F and 2/11/21 at 113F. (AES,HSLS on 2/23/21)] |
02/03/2021
| Implemented |
| 6400.72(a) | There are not screens in the windows of Individual #1's bedroom. The windows are able to be opened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | On January 27, a screen was placed in the bedroom window by maintenance. The POC: Joanne Walker (Program Specialist implemented a checklist to do inspection every 30 days to make sure all screens, windows, and doors are in good conditions. If for any reason they are not Joanne will make sure all repairs are made and document when the repair was made. The POC will be implemented immediately. At least quarterly for 1 year, the CEO shall review the aforementioned checklist to ensure completion and repairs are made and all homes are in good repair and safe conditions are maintained at all times. Documentation of reviews shall be kept. [On 2/22/21, a copy of the completed "physical site checklist", signed by the PS on 1/31/21 and CEO on 2/1/21 was provided to the Department. (AES,HSLS on 2/23/21)] |
01/27/2021
| Implemented |
| 6400.112(f) | The door at the front of the home was used at the exit route in the fire drills held from 8/2019 to 12/2020. The home has two exit routes. | Alternate exit routes shall be used during fire drills. | On February 2, 2021 a fire drill was complete using an alternate exit route (back sliding doors) . Joanne Walker (Program Specialist) will audit fire drill monthly for a year to assure compliance is being met. If the fire drills are not being done correctly Joanne will correct the issue with displinary action, fire drill will be done correctly to assure compliance and prevent violation from reoccurring in the future. The plan of correction was implemented February 2nd, 2021. The CEO shall educate all staff person responsible for conducting fire drills on the requirements 6400.112(f). Documentation of the training shall be kept. A least quarterly for 1 year, the CEO shall audit all fire drill records to ensure fire drills are held as required. Documentation of all audits by the Program Specialist and CEO shall be kept. [On 2/22/21, a copy of the fire drill log was provided to the Department showing the "sliding door in living room" as the evacuation route and a monthly audit signed by the PS on 2/3/21 reading "fire drill was completed by staff using alternative route." (AES, HSLS on 2/23/21)] |
02/02/2021
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | Individual #1's physical examination completed 1/11/19 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On September 18, 2019, Joanne Walker (Program Specialist), spoke with DH individual #1 PCP requesting to indicate any medical information pertinent to diagnosis and treatment in case of an emergency. On September 18, 2019 Joanne Walker faxed the most recent physical form to PCP office to be completed by PCP. On September 3, 2019 the CEO updated the agency physician medical form to reflect the requested information (that all physical's performed should indicate any medical information pertinent to diagnosis and treatment in case of emergency. Joanne Walker (program specialist) will check all physical form and document the dates the dorms were completed. If Joanne finds any forms that need to be corrected she will contact PCP to get issued corrected within 30 days to remain in compliance with the chapter and to assure the same violation do not occur again. Upon completion and receipt of documentation, the program specialist shall review to ensure all required information is completed and there are not any required areas left blank. Immediately. The CEO shall educate the program specialist and trained staff person shall review all individuals completed physical examination to ensure all required information is included and there are not any areas of required information left blank. The CEO will audit physical within 30 days of completion to make sure all pertinent information is completed. Documentation will be kept. [Individual #1's physical examination was update to include "no" for medical information pertinent to diagnosis and treatment in case of an emergency. (AES,HSLS on 9/24/19)] |
09/17/2019
| Implemented |
|
|