| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | The windows in Individual 2's bedroom do not have screens. | Screens, windows and doors shall be in good repair. | During the inspection, the window screens had been taken for repairs. In accordance with 55 PA Code Chapter 6400.72(b), the window screens were replaced the day following the inspection by the Program Specialist |
03/08/2024
| Implemented |
| 6400.104 | Records did not contain a notice 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 |
| 6400.112(d) | Fire drills do not meet the evacuation time requirement. Additionally, drills were not attempted during those non-compliant months (October and November 2023). | 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) | A sleep drill has not been held since the arrival of the individual at the home. Based on current fire drill records, February's drill is required to be a sleep drill. | 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) | There is no documentation of completed fire safety training for Individual 2. | 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)(7) | For individual 2, the record says that a gynecological visit hasn't been completed in more than two years. In the record, there is no report of scheduled, refused, and subsequently rescheduled appointments. | 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 55 PA Code Chapter 6400.141(c)(7), the Program Specialist scheduled a GYN visit for the individual for 3/13/24 |
03/20/2024
| Implemented |
| 6400.142(a) | For individual 2, the record did not contain verification of a completed dental visit. | 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 has scheduled a dental appointment for 3/25/24 where the dental plan will be requested from the dentist |
04/01/2024
| Implemented |
| 6400.142(h) | For Individual 2, the record did not contain a dental plan. | The dental hygiene plan shall be kept in the individual's record. | In accordance with 55 PA Code Chapter 6400.142(a), the Program Specialist has scheduled a dental appointment for 3/25/24 where the dental plan will be requested from the dentist |
04/01/2024
| Implemented |
| 6400.181(a) | For individual 2, the record didn't contain an initial assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | In accordance with 55 PA Code Chapter 6400.181(a), the Program Specialist will ensure that the individual has an initial assessment completed in its entirely within the file, and an assessment completed in its entirety annually thereafter. Because individual 2 came into the program as emergency respite there was no prior assessment completed on the individual in the year priory's to entry into the residential program. |
03/11/2024
| Implemented |
| 6400.181(e)(10) | For individual 2, the record did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | 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. |
04/01/2024
| Implemented |