| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | For the new hires, the application does not include a Pennsylvania residency attestation. | 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.
| In accordance with 55 PA Code Chapter 6400.21(a), The agency has created and implemented a job application for new hires as well as current staff to complete that includes a Pa residency attestation. . The program specialist is responsible for ensuring via the administrative assistant that all staff new and current have completed applications that include the Pa residency attestation as a part of their hiring documents. |
03/08/2024
| Implemented |
| 6400.21(b) | For the new hires, the necessary background checks weren't completed because PA residency status was not correctly determined. Without this knowledge, there is no way to determine if a PA criminal check, or the broader FBI backgroun check were needed. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| In accordance with 55 PA Code Chapter 6400.21(b , The agency has created and implemented a job application for new hires as well as current staff to complete that includes a Pa residency attestation. . The program specialist is responsible for ensuring via the administrative assistant that all staff new and current have completed applications that include the Pa residency attestation as a part of their hiring documents. Staff that have no attested to PA residency will be required to submit FBI background check as a condition of hire. |
03/08/2024
| Implemented |
| 6400.32 | Individual 1's record did not contain a signed copy of rights. | An individual may not be deprived of rights.
| In accordance with 55 PA Code Chapter 6400.32 , The Program Specialist had the guardian ad litem send the completed admission packet that includes a signed copy of "Individual Rights". |
03/08/2024
| Implemented |
| 6400.67(a) | There are separated floorboards in the living room and buckling floorboards in the kitchen. Both present a tripping hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | In accordance with 55 PA Code Chapter 6400.67(a), the CFO has scheduled an appointment with the company that originally installed the wood flooring to assess the cost and time frame of the needed repair to be completed. |
04/01/2024
| Implemented |
| 6400.72(a) | The front bedroom, and Individual 1's room, both have windows without screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | During the inspection, the window screens had been taken for repairs. In accordance with 55 PA Code Chapter 6400.72(a), the window screens were placed the day following the inspection by the Program Specialist |
03/08/2024
| Implemented |
| 6400.72(b) | The blinds in the windows of the front bedroom are broken. | Screens, windows and doors shall be in good repair. | In accordance with 55 PA Code Chapter 6400.72(b), the Program Specialist replaced the broken blinds on the day following the inspection. |
03/08/2024
| Implemented |
| 6400.82(e) | There is no non-slip mat in the shower stall. Despite the report of the ladies persistently removing it, alternatives should be considered such as adhesive grips being added. | Bathtubs and showers shall have a nonslip surface or mat. | In accordance with 55 PA Code Chapter 6400.82(e), the non skid mat has been replaced in the shower by the lead DSP. |
03/08/2024
| Implemented |
| 6400.104 | A notice was not sent to the local fire department. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| In accordance with 55 PA Code Chapter 6400.104, The CFO scheduled a fire safety training with the Philadelphia Fire Department for 3/5/24, in order to have all staff properly trained, submit the approbate notices, check fire extinguishers, and update and have approved evacuation procedures |
03/11/2024
| Implemented |
| 6400.111(a) | The upstairs hallway extinguisher is overcharged. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | In accordance with 55 PA Code Chapter 6400.104, The CFO scheduled a fire safety training with the Philadelphia Fire Department for 3/5/24, in order to have all staff properly trained, submit the approbate notices, check fire extinguishers, and update and have approved evacuation procedures |
03/11/2024
| Implemented |
| 6400.112(d) | Completed fire drills do not meet the evacuation time requirement. Additionally, drills were not reattempted during those non-compliant months (June, July, August, September, November, December in 2023, and January 2024).
It is recommended that a fire safety expert be brought in to assess the fire safety/evacuation needs of the home to potentially re-determine if an extended evacuation time is needed. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | In accordance with55 PA Code Chapter 6400.112(d), The CFO scheduled a fire safety training with the Philadelphia Fire Department for 3/5/24, in order to have all staff properly trained, submit the approbate notices, check fire extinguishers, and update and have approved evacuation procedures |
03/11/2024
| Implemented |
| 6400.112(e) | Based on the indicated drill times, sleep drills were not held from April 2023 to present. | A fire drill shall be held during sleeping hours at least every 6 months. | In accordance with 55 PA Code Chapter 6400.112(e), fire drills during sleeping hours have been scheduled during the month of February by the Program Specialist |
03/11/2024
| Implemented |
| 6400.112(h) | The fire drill form does not state where the designated meeting place is for the individuals to evacuate to. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | In accordance with 55 PA Code Chapter 6400.112(h), the Fire Drill Record has been updated to include the designated meeting place by the administrative assistant. |
03/08/2024
| Implemented |
| 6400.113(a) | Individual 1's record did not contain documentation of completed fire safety training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | In accordance with 55 PA Code Chapter 6400.113(a), the Program Specialist has had the individual sign the attestation of Fire Safety Training. |
03/11/2024
| Implemented |
| 6400.141(c)(3) | Individual 1's record did not contain an immunization history. Correspondence between the provider and the guardian ad litem was provided. However, given the timeline since the individual was admitted to the provider, and the regular involvement of the individual's family, obtaining an immunization history should be achievable. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | In accordance with 55 PA Code Chapter 6400.181(e)(10), the administrative assistant has created a template to capture individuals' lifetime medical history and/or the medical history being developed since the individual entered the program where precious history is not available. Individual 1 does have a court appointed guardian ad litem, and a grandmother with whom she did not reside with until she was an adult, and the administrative with add this information to the individual's medical history as documentation |
03/18/2024
| Implemented |
| 6400.141(c)(6) | For individual 1, record of a completed TB test was not provided. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | In accordance with 55 PA Code Chapter 6400.141(c)(6), the Program Specialist has made an appointment of for the individual with their PCP to have TB screening completed, and the health assessment updated on 3/12/24. The lead DSP will be responsible for transporting the individual to the appointment and ensuring that the form is updated or proof of TB screening results are obtained |
03/18/2024
| Implemented |
| 6400.141(c)(7) | Individual 1's record did not contain documentation of the most recent gynecological visit. Documentation validating a scheduled appointment, then a subsequent refusal and reschedule were not provided. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | In accordance with the Program Specialist scheduled a GYN visit for the individual which occurred on 2/27/24, the lead DSP took the individual to the visit. |
03/08/2024
| Implemented |
| 6400.142(a) | Individual 1's record did not contain documentation of the most recent dental visit, scheduled appointment, and/or refusal to attend an appointment that subsequently rescheduled. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | In accordance with 55 PA Code Chapter 6400.142(a), the Program Specialist obtained proof of a previous dental appointment scheduled by the provider and the subsequent referral to a dental specialist where the dental plan will be requested from the dentist |
03/11/2024
| Implemented |
| 6400.151(c)(3) | For staff 1, there is no documentation in the record that the person is free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | In accordance with 55 PA Code Chapter 6400.141(c)(6), the Program Specialist has made an appointment of for the individual with their PCP to have TB screening completed, and the health assessment updated on 3/12/24. The lead DSP will be responsible for transporting the individual to the appointment and ensuring that the form is updated or proof of TB screening results are obtained |
03/18/2024
| Implemented |
| 6400.181(e)(10) | Individual 1's record did not contain a lifetime medical history. Or information reporting a medical history that was being developed upon the individual's arrival. | The assessment must include the following information: A lifetime medical history. | In accordance with 55 PA Code Chapter 6400.141(c)(3), the administrative assistant has created a template to capture individuals' lifetime medical history and/or the medical history being developed since the individual entered the program where precious history is not available. |
03/18/2024
| Implemented |
| 6400.217 | Individual 1's record did not contain a signed consent for info release. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| In accordance with 55 PA Code Chapter 6400.217, the Program Specialist was able to obtain all consent forms from the Guardia mad litem on the individual's behalf. |
03/08/2024
| Implemented |
| 6400.46(a) | For staff 1 and staff 2, their records did not include a completed fire safety training. | 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. | In accordance with 55 PA Code Chapter 6400.46(a), The CFO scheduled a fire safety training with the Philadelphia Fire Department for 3/5/24, in order to have all staff properly trained, submit the approbate notices, check fire extinguishers, and update and have approved evacuation procedures |
03/12/2024
| Implemented |
| 6400.46(d) | For staff 1, there is no record of completed CPS/first aid training. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | In accordance with 55 PA Code Chapter 6400.46(d) the Program Specialist ensured that staff 1 completed a CPR training and submitted the certificate for it to be added to their file. |
03/08/2024
| Implemented |
| 6400.51(b)(1) | For staff 1 and staff 2, their files don't contain information specifying that an orientation took place prior to the staff member working with the individuals (there are training records, but these are not identified that they are included as part of orientation). | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | In accordance with 55 PA Code Chapter 6400.51(b)(1), The administrative assistant has added a section in the staff files that identifies trainings that are a part of the "Orientation" in order to make clear that each staff was oriented prior to working with individuals, |
03/08/2024
| Implemented |
| 6400.51(b)(1) | The CEO and PS training hours are insufficient and do not meet the time or training course title requirements. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | In accordance with 55 PA Code Chapter 6400.51(b)(1), the CEO and PS have been required to completed their required trainings "prior to 3/31/24 which is the end of the provider's training year. The administrative assistant is responsible for ensuring that all training hours are completed and proof of training are submitted and maintained in their files. |
04/05/2024
| Implemented |
| 6400.52(a)(1) | For staff 1 and staff 2, less than the required 24hrs of annual training were completed. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | In accordance with 55 PA Code Chapter 6400.52(a)(1), all staff have been given the training topics and courses to be completed by 3/31/24 which is the end of the agency training year by the administrative assistant |
04/05/2024
| Implemented |