| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | There was a clear substance that staff identified as hand sanitizer being stored in an unlabeled soap container. | Poisonous materials shall be stored in their original, labeled containers. | 55 PA Code Chapter 6400.62(c) - There was a clear substance that staff identified as hand sanitizer being stored in an unlabeled soap container.
Biacon Supervisor will check to ensure poisonous materials will be kept in their original containers during their weekly rounds. |
04/10/2023
| Implemented |
| 6400.64(f) | The outside trash receptacles were overflowing with garbage, | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | 55 PA Code Chapter 6400.64(f) - The outside trash receptacles were overflowing with garbage,
Biacon Staff will take trash out of the designated days weekly. In the event a trash day is missed, biacon staff will notify supervisor so an additional trash can will be made available to contain additional trash. |
04/10/2023
| Implemented |
| 6400.71 | The emergency contact list did not include the phone number for poison control. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| 55 PA Code Chapter 6400.71 - The emergency contact list did not include the phone number for poison control.
Biacon's Program Specialist will ensure all emergency contact list include the number for poison control during her daily rounds. |
04/10/2023
| Implemented |
| 6400.72(a) | The bedroom located on the first floor had an open window with no screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 55 PA Code Chapter 6400.72(a) - The bedroom located on the first floor had an open window with no screen.
Biacon supervisor will check all biacon homes to ensure regulatory compliance during their daily rounds. All windows wil be check and if windows are not operable or are without screens, biacon supervisor will notify maintenance to fix the issue within 24-48 hours |
04/10/2023
| Implemented |
| 6400.76(a) | The living room sofa is broken. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 55 PA CODE Chapter 6400.76(a) - the living room sofa was broken.
Biacon staff will notify maintenance of any broken furniture so all equipment will be in good working condition. Maintenance will request a purchase order for any broken furniture within 24-48 hours. |
04/10/2023
| Implemented |
| 6400.77(b) | There was no tape 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. | 55 PA CODE CHAPTER 6400.77(b) - 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.
Biacon supervisor will check to ensure all first aid kits have the tape and all required items per regulations during their weekly rounds. |
04/10/2023
| Implemented |
| 6400.82(f) | There were no paper towels or hand towels in the bathrooms of the home. | 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. | 55 PA CODE CHAPTER 6400.82(f)- 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.
Biacon Supervisor will ensure all bathrooms have a paper towel or cloth towel in each bathroom during their weekly rounds. |
04/10/2023
| Implemented |
| 6400.110(a) | There is no smoke detector on the second floor of the home. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 55 PA CODE CHAPTER 6400.110(a)- A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
Biacon supervisor will make sure all smoke detectors are present on each floor of the home during their weekly rounds. |
04/10/2023
| Implemented |
| 6400.110(c) | The smoke detector located on the first floor is in the staff office, not in a common area. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | 55 PA CODE CHAPTER 6400.110(c)The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways.
Biacon supervisors will check each home to ensure smoke detectors are present on each floor and in a common area during their weekly rounds. |
04/10/2023
| Implemented |
| 6400.110(e) | The smoke detectors on the first floor and basement are 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. | 55 PA CODE CHAPTER 6400.110(e) - 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.
Biacon Staff will ensure all smoke detectors are interconnected during the monthly fire drill. If not interconnected, staff will notify maintenance to fix the issue within 24 hours. |
04/10/2023
| Implemented |
| 6400.111(a) | There was no fire extinguisher on the first or second floors of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 55 PA CODE CHAPTER 6400.111(a) -There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.
Biacon supervisors will check floor of the homes to make sure each floor has a fire extinguisher with a minimum 2-A rating during their weekly rounds. |
04/10/2023
| Implemented |
| 6400.111(c) | There was no fire extinguisher in the kitchen of the home. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | 55 PA CODE CHAPTER 6400.111(c) - A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a).
Biacon supervisor will check each floor of the homes to make a fire extinguisher with a minimum 2A-10BC rating is present during their weekly rounds |
04/10/2023
| Implemented |
| 6400.166(a)(13) | Several medication administrations were not signed for in Individual #2's MAR in February and March 2023. Their 4PM administration of polyeth. glyc. powder was not signed for at all during March 2023. All medications were not signed for during the 12PM administration on 2/25/23. On 2/26/23, the 4PM medication administrations were not signed for, and their 8PM administration of mirtazapine 15mg. and 30 mg. tablets were also unsigned. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | 55 PA CODE CHAPTER 6400.166(a)(13)- A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.
staff person O.D, F.B were given medication administration practicum on 4/9. Staff person M.M was given a medication practicum on 4/11 to ensure proper medication records are kept including their signatures and initials. The medication administration practicum was done by biacons trainer. |
04/11/2023
| Implemented |