| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Was unable to locate two-year attestation for new hires, staff one and two, per regulation discussion:
Discussion:
Employees who do not currently reside in Pennsylvania or who have not held permanent residency in Pennsylvania for the two consecutive years prior to beginning employment also need a report of federal criminal history record information from the Federal Bureau of Investigation ("FBI check"). | 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.
| As part of the Post-Employment on-boarding requirements and screenings, potential employees will successfully complete the required Background Checks and Attestation form.
Form 417-PA Attestation of Residency in Pennsylvania was created to supplement the application and added as an item to the Form 147-HR New Hire Packet Checklist and Cover Sheet which states SUBMIT PACKET with all required documentation to HRInbox@sunrisegroup.org
This Attestation of Residency in Pennsylvania will be completed and signed by the potential and all current employees including Staff 1and 2 . Persons who are not residents of Pennsylvania for at least 2 years will require an FBI Background Check. This completed and signed form must be submitted to HRInbox@sunrisegroup.org and filed in the Employee Personnel Record. |
03/31/2025
| Implemented |
| 6400.67(a) | The closet door in Individual #1s room was broken and completely off track. Staff Members state that they have purchased beaded curtains as Individual report doors continue to break. | Floors, walls, ceilings and other surfaces shall be in good repair. | The closet doors were replaced with beaded curtains that the ladies chose. A Monthly Life Home Checklist will be completed by the Residential Managers to ensure all items and physical plant issues are identified and resolved. Any items that cannot be resolved by the Residential Manager will be brought to the Area Director.
See email picture of beads |
04/02/2025
| Implemented |
| 6400.77(b) | The first aid kit was missing a thermometer and tweezers. | 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. | The Residential Manager and LPN are responsible for maintaining the first aid kit with all its required items. The first aid kit is part of the Monthly Home Checklist. Additional thermometers and first aid kits have been purchased for back up. |
04/30/2025
| Implemented |
| 6400.104 | The home did not have a letter to the Fire Dep't on file. | 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.
| The Residential Manager will notify the fire department of the address and exact location of the bedrooms of the individuals who need assistance for evacuation during an actual fire.
see email attchment |
05/01/2025
| Implemented |
| 6400.112(d) | Individuals should be able to evacuate the entire building within 2.5 minutes unless otherwise specified by a fire safety expert. Fire Drills completed in the following months were timed greater than 2.5 minutes:
July 2024; Aug 2024; | 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. | The individuals in this home are very independent, two are usually able to evacuate under 21/2 minutes. One person is able but not always willing. Staff have been retrained on how to use the stopwatch for accurate evacuation times.
The Residential Manager and other key staff were trained on Fire Safety Train the Trainer from a certified fire expert from the Lockton company on 4/10/25. It was a comprehensive training that our managers can add to the specific home fire training for the individuals and staff. In addition, each home has fire sprinklers in addition to fire alarms to ensure safety and extra time for slower evacuation times if necessary.
See letter
See PowerPoint |
03/26/2025
| Implemented |