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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(b) | Staff #5 received fire safety training on 5/5/22, however there is no documentation to support that the training was completed by a fire safety expert and included the training areas specified in subsection (a). | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Provider has contracted with Allentown Fire Department to facilitate the annual fire training. Captain Christopher will be facilitating the training on May 10 & May 17. |
06/01/2023
| Implemented |
| 6400.50(a) | Staff #5 received a certificate of completion from the American Red Cross dated 5/2/22. The record does not include the content of the training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Providers trainer has updated the training sign in sheet to reflect more detail, including the length of time and training content. |
05/01/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Fire drills conducted on 6/8/20, 8/29/20, 10/13/20, 10/26/20, 11/15/20, 1/22/21, 2/22/21 and 3/30/20 exceeded the allotted 2 ½ minutes to evacuate the building. There was no documentation of problems that were encountered during the drill that resulted in exceeding the allotted time frame. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All LVHS house directors attended a Training Meeting on April 30, 2021 2:00pm-5:30pm (See Appendix 5). In this meeting Regulation 6400.101 - 6400.114 was reviewed (with specific emphasis on 6400.112). RCG 112a ¿ 112i was also reviewed in the training. Further, a fire expert (Upper Macungie Fire Chief) has been scheduled to come to the home on May 26, 2021 to observe a fire drill with the individual who has trouble evacuating in the regulatory specified time frame. Provider will implement the recommendations made by the fire expert. |
04/30/2021
| Implemented |
| 6400.112(d) | Fire drills conducted on 6/8/20, 8/29/20, 10/13/20, 10/26/20, 11/15/20, 1/22/21, 2/22/21 and 3/30/20 exceeded the allotted 2 ½ minutes for evacuation. Evacuation time for the 6/8/20 drill was 3 minutes (min) 01 seconds (sec), the fire drill on 8/29/20 was 3 min 38 seconds, the fire drill on 10/13/20 was 3 min 45 seconds, 10/26/20 was 2 min 41 sec, 11/15/20 was 3 min 15 sec, 1/22/21 was 3 min 12 sec, 2/22/21 was 3 min 08 sec and 3/30/20 was 2 min 26 sec. | 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. | All LVHS house directors attended a Training Meeting on April 30, 2021 2:00pm-5:30pm (See Appendix 5). In this meeting Regulation 6400.101 - 6400.114 was reviewed (with specific emphasis on 6400.112). RCG 112a ¿ 112i was also reviewed in the training. Further, a fire expert (Upper Macungie Fire Chief) has been scheduled to come to the home on May 26, 2021 to observe a fire drill with the individual who has trouble evacuating in the regulatory specified time frame. Provider will implement the recommendations made by the fire expert. |
04/30/2021
| Implemented |
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