|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | Bathroom window has no screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The identified missing screens were replaced immediately. To ensure compliance with 55 PA Code Chapter 6400.72(a), we will implement a detailed and specific plan to assure that all windows have screens in place. This plan will be executed on a monthly basis and will involve the use of a comprehensive checklist as outlined below. |
06/12/2024
| Implemented |
| 6400.80(b) | Exterior wall, big gaps between bricks, need to be sealed to avoid rodents. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The openings identified in the exterior wall of the home at 5136 Haverford Ave, will be repaired immediately. To ensure compliance with the Office of Developmental Programs (ODP) regulation 55 PA Code Chapter 6400.80(b), our organization will adopt a comprehensive inspection and maintenance plan. This plan outlined below in the Plan to Maintain Compliance. |
07/10/2024
| Implemented |
| 6400.112(e) | No sleep fire drills over the past year. | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight fire drill will be conducted in June, 2024. To ensure compliance with 55 PA Code Chapter 6400.112(g), we will implement a plan to ensure fire drills are conducted at different times and days:
1. Schedule Diversity: Fire drills will be scheduled at various times throughout the day and night to ensure all staff and residents are familiar with the procedure. This will include early morning, afternoon, evening, and late-night drills. The schedule will be randomized to avoid predictability.
2. Record Keeping: LNL will maintain fire drill log that records the date, time, and participants of each drill. The log will also include any issues encountered during the drill and the steps taken to address them. A detailed plan to maintain compliance is outlined below.
2. Record Keeping: LNL will maintain fire drill log that records the date, time, and participants of each drill. The log will also include any issues encountered during the drill and the steps taken to address them.
2. Record Keeping: LNL will maintain fire drill log that records the date, time, and participants of each drill. The log will also include any issues encountered during the drill and the steps taken to address them.
3. Monthly Reviews: The program manager will review the fire drill log on a monthly basis. This review will assess the diversity of drill times and days, the participation rate, and the resolution of any issues that have been recorded.
4. Staff Training: All staff members will receive training on the importance of fire drills and the need for them to occur at different times and on different days. This training will also cover how to properly record a fire drill in the log. Introduction to the new fire drill log will occur during the weekly staff meeting on 6/19/24. The fire drill log will also be incorporated into the annual fire safety awareness training assigned to all staff.
Person centered perspective. Individuals will be informally interviewed to assess the impact of fire drills on their subjective experience. Potential negative emotional impact of the fire drill will be mediated by education and counseling when applicable. The individual¿s input will be valuable in identifying potential issues and improving the effectiveness of the drills.
Continuous Improvement: LNL will use the monthly reviews as an opportunity for continuous improvement. If the reviews identify any trends or recurring issues, we will adjust the fire drill procedures accordingly. A detailed monthly review process coupled with a staff training protocol is outlined below in the Plan to Maintain Compliance. |
07/01/2024
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | A couch that was being stored on the outside porch was not in good condition. The couch was covered in animal hair, discolored and is a breeding ground for insects, rodents and stray animals.
There were several items leaning on the side of the home that were not in closed receptacles, including a generator, rolled up carpet, pieces of drywall and a broken stool. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The couch was removed from the property. It now clear of debris and and is maintained. |
10/31/2022
| Implemented |
|
|