| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There were no tweezers in first 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. | ¿ Program Specialist procured a pair of tweezers suitable for the first aid kit.
¿ Program Specialist place tweezers in the first aid kit.
¿ Program Specialist conducted a thorough inventory check of the entire first aid kit to ensure no other items are missing or expired.
¿ Program Specialist is the designated staff member for ongoing inventory management.
¿ Program Specialist created and implemented a checklist for documenting inventory checks and restocking activities.
¿ The Program Specialist educated and trained DSPs on maintaining the first aid kit's contents and following the inventory check procedures.
¿ The Program Specialist Implemented a monthly inventory checks and restocking procedures to ensure ongoing compliance. |
09/07/2023
| Implemented |
| 6400.106 | A furnace inspection was not provided. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| ¿ The Program Specialist scheduled an immediate inspection of the furnace by a qualified technician.
¿ The Program Specialist documented and addressed any necessary repairs or maintenance identified during the inspection.
¿ The records of the inspection, repairs, and maintenance performed were stored in the house binder.
¿ Develop a checklist or tracking system to monitor and document future furnace inspections.
¿ The Program Director educated and trained the Program Specialist on the importance of furnace inspections and maintenance. |
09/07/2023
| Implemented |
| 6400.111(a) | There was no fire extinguisher in attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | ¿ The Program Specialist will immediately install a fire extinguisher in the attic to address the deficiency.
¿ The Program Specialist will ensure that the newly installed fire extinguisher is appropriate for the type of fire hazards present in the attic and is in compliance with relevant regulations and standards.
¿ The fire extinguisher will include the date and details of the equipment by a qualified fire safety professional.
¿ The Program Specialist is the responsible staff member to oversee fire safety measures in the attic and conduct regular checks according to 55 PA Code Chapter 6400.111(a).
¿ The Program Director educated and trained the Program Specialist on fire safety procedures, including the location and proper use of the attic fire extinguisher. |
09/07/2023
| Implemented |