| 6400.15(a) | The agency did not fully complete the self-assessment, dated 3/1/20, to measure and record compliance with each regulation for Title 55 Pa. Code Chapter 6400. The sections, to record if each regulation was either compliant, a violation, not applicable or not measured, were left blank. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| On January28, 2021, (Program Specialist) complete the self assessment. Program Specialist will make sure that a self-assessment for each site is completed 3-6 months prior to on site inspection. CEO will audit assessment to assure the assessment is complete and all correction are made to assure compliance and assure that the same violation do not reoccur in the future. The POC will be implemented as of February 1, 2021. Upon receipt of certificate of compliance, the CEO or designee shall develop and implement a tracking system to ensure the self-assessment is completed timely. Prior to 3 months of the expiration date of the current certificate of compliance the CEO shall audit all completed self-assessment to ensure completion, timely. Documentation of audits shall be kept. [On 2/22/21, copies of the completed self-assessment, without a completion date, was provided to the Department. (AES,HSLS on 2/23/21)] |
02/01/2021
| Implemented |
| 6400.110(c) | The only smoke detector in the home is in the bedroom of the home. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | On January 29, 2021, Joanne Walker (Program Specialist) purchased a placed smoke detector outside of bedroom within 15 feet of the bedroom. The Program specialist will immediately audit all homes quarterly for 1 year for smoke detectors location to ensure compliance is being met. Within 30 days of receipt of plan of correction, all staff will be trained by program specialist on regulation 6400.110. The CEO will audit all location quarterly for 1 year to ensure the violation do not reoccur in the future. Documentation will be kept. [At least monthly, all smoke detectors will be checked to ensure operability, as required, and documentation of the checks will be kept. Audit documentation for monthly and quarterly audits of smoke detectors signed by CEO on 1/30/21 was provided to the Department on 2/22/21. (AES,HSLS on 2/23/21)] |
01/29/2021
| Implemented |