| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not fully complete the self-assessment, dated 4/20/20, 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 January 28, 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 and "physical site checklist", signed by the PS on 1/31/21 and CEO on 2/1/21 was provided to the Department. (AES,HSLS on 2/23/21)] |
01/28/2021
| Implemented |
| 6400.74 | The outside wooden steps off the porch from kitchen door at the back of the home do not have a non-skid surface. | Interior stairs and outside steps shall have a nonskid surface.
| On January 28, 2021 the non-skid surfaces was placed on the outside wooden steps. (Program Specialist will implement an inspection monthly to ensure all indoor and outdoor steps have a nonskid surface. If for any reason they don't Program Specialist will make sure the issue is corrected and document when the issue was corrected. The POC will be implemented immediately. At least quarterly for 1 year, the CEO shall review the aforementioned inspection to ensure completions and repairs are made and all homes are in good repair and safe conditions are maintained at all times. Documentation of reviews shall be kept. |
01/28/2021
| Implemented |
| 6400.110(e) | The home has a first floor, second floor, basement and attic. The smoke detectors on each floor are 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. | One February 3rd, 2021 a certified electrician started installation of interconnected smoke detectors on each floor in the house.Program Specialist will inspect all homes in the future to ensure if the homes have 3 or more floor the smoke detectors are interconnected. The installation will be checked 3 times to make sure all smoke detector are interconnected and operating correctly. Smoke detectors will checked monthly for functionality. The Program Specialist will train all staff within 30 days of receipt of POC on regulation 6400.110 to ensure the same violations don't reoccur in the future. At least quarterly for 1 year, the CEO shall review the aforementioned inspection to ensure compliance. Documentation of inspection will be kept. [On 2/22/21, a copy of the quarterly CEO audit for smoke detectors and physical site checklist was provided to the Department. (AES,HSLS on 2/23/21)] |
02/03/2021
| Implemented |