| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | The two windows, which are able to be opened, located in Individual #1 bedroom do not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Plan of Correction for: 55 PA Code Chapter 6400.72(a) Window Screens
How it was corrected: On April 28, 2021 AHH CEO had the AHH Maintenance Team provide the measurements and then ordered window screens for the individual¿s room. On June 11, 2021 or if received prior to the AHH Maintenance team will install the window screens.
When it was corrected: April 28, 2021 ordered and to be installed no later than June 30, 2021
Who made the correction: A Helping Home, LLC CEO and AHH Maintenance
What specific change will be made: The AHH CEO ordered window screens and the AHH Maintenance team will install once delivered.
Who will make the change: AHH CEO and AHH Maintenance |
06/30/2021
| Not Implemented |
| 6400.110(e) | The home has three stories, a basement, first floor and second floor. The smoke detector on the second floor of the home is not interconnected and audible throughout the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Plan of Correction for: 55 PA 6400.110 (e) Smoke Detectors and Fire Alarms
How was it Corrected: A Helping Home, LLC will input an interconnected fire alarm system that is audible throughout the home.
When it was corrected: On May 8, 2021
Who made the corrections: AHH CEO purchased the interconnected fire alarm system to ensure the necessary compliance from Home Depot (see attached receipt).
What Specific Change will be made: The fire alarm system was purchased and installed to have it interconnect to ensure safety in the home.
Who will make the change: A Helping Home, LLC management; CEO, , Associate Director and AHH Maintenance |
05/08/2021
| Implemented |
| 6400.141(c)(3) | Individual #1's most recent tetanus immunization was on 8/31/2005. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Plan of Correction for: 55 PA 6400.141(c)(3) Immunizations
How was it Corrected: The AD will ensure that all newly admitted individuals would have their immunizations completed and up-to-date prior to admittance. If there is a religious exemption associated with the vaccination the AD will ensure the proper documentation is present.
When it was corrected: On May 5, 2021
Who made the corrections: The AD
What Specific Change will be made: The AD will ensure that A Helping Home, LLC will have appropriate medical documentation for all individuals prior to admission.
Who will make the change: The AD will make the changes. |
05/05/2021
| Not Implemented |
| 6400.163(h) | Ziprasidone 60mg, take 1 capsule by mouth twice a day for mood disorder, prescribed to Individual #1 was discontinued on 4/20/2021. The medication remained in Individual #1's medication storage area. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Plan of Correction for: 55 PA 6400.163(h) Storage of medications
How it was corrected: On April 28, 2021 at 11am AD and Office Manager disposed of the discontinued medication. Both signed the medication disposal form documenting the disposal. (see attached)
When it was corrected: April 28, 2021 at 11am
Who made the correction: AHH Management; AD and Office Manager
What specific change will be made: DCS Staff will be trained to empty the medication storage box each time medication is administered and compare the label to log of each to ensure that there are no discontinued medications remaining in the medication storage box. DCS Staff will initial off of the Daily Job Responsibilities Log after completing the task. (see attached example)
Who will make the change: A Helping Home, LLC Management: AD and House Supervisor |
05/15/2021
| Not Implemented |