| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a large stain on the carpet in the living room. | Clean and sanitary conditions shall be maintained in the home. | 1. The provider will ensure that all physical aspects of the home are in good repair by completing the residential facility inspection on a biannual basis in June and December as well as routine checks of the site by all staff and completion of the provider self-inspection as outlined in regulation. Needed repairs are to be reported through the internal online maintenance reporting system, Manager Plus or if of an urgent nature a verbal report shall be made immediately. Additionally cleaning issues are expected to be reported by staff immediately so that remediation can occur and the facility remain in good condition. Staff are expected to see it, report it.
2. Immediate notification of deficiency was made to Karen Roberts, Maintenance. Carpet cleaning company was contacted with cleaning occurring during the last week in October.
3. To prevent reoccurrence of this issue the Operations Director/Program Specialist shall utilize the state issued self-inspection form as outlined in regulations noting any deficiencies as well as the bi-annual internal facility inspection report. Deficiencies noted will be recorded and submitted for installation or repair to the maintenance department. Any issues noted to be a potential hazard shall be reported and rectified immediately.
4. Operations Directors/Program Specialists shall complete the stated forms, with monitoring and approval provided by the Regional Director, the forms shall be completed as outlined reviewed by the Operations Director/Regional Director. Any instances of noncompliance shall be logged into the Manager Plus system used by agency maintenance personnel or in instances of a potential hazard notification shall be made via telephone with resolution (either situation made safe or repaired) expected immediately. |
10/31/2018
| Implemented |
| 6400.73(a) | The stairs leading to the lower level have two steps plus the landing, and there is no handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | 1. The provider will ensure that all physical aspects of the home are in good repair by completing the residential facility inspection on a biannual basis in June and December as well as routine checks of the site by all staff and completion of the provider self-inspection as outlined in regulation. Needed repairs are to be reported through the internal online maintenance reporting system, Manager Plus or if of an urgent nature a verbal report shall be made immediately.
2. Immediate notification of deficiency was made to Karen Roberts, Maintenance. Maintenance on site during the week of 10/21/18 to determine what corrective action was needed. Full repair was completed on 11/01/18.
3. To prevent reoccurrence of this issue the Operations Director/Program Specialist shall utilize the state issued self-inspection form as outlined in regulations noting any deficiencies as well as the bi-annual internal facility inspection report. Deficiencies noted will be recorded and submitted for installation or repair to the maintenance department. Any issues noted to be a potential hazard shall be reported and rectified immediately.
4. Operations Directors/Program Specialists shall complete the stated forms, with monitoring and approval provided by the Regional Director, the forms shall be completed as outlined reviewed by the Operations Director/Regional Director. Any instances of noncompliance shall be logged into the Manager Plus system used by agency maintenance personnel or in instances of a potential hazard notification shall be made via telephone with resolution (either situation made safe or repaired) expected immediately. |
11/01/2018
| Implemented |
| 6400.80(b) | The outside, concrete sidewalk leading to the front door of the home was broken and crumbling, causing a potential tripping hazard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 55 PA Code Chapter 6400.80(b)
The outside, concrete sidewalk leading to the front door of the home was broken and crumbling, causing a potential tripping hazard.
1. The provider will ensure that all physical aspects of the home are in good repair by completing the residential facility inspection on a biannual basis in June and December as well as routine checks of the site by all staff and completion of the provider self-inspection as outlined in regulation. Needed repairs are to be reported through the internal online maintenance reporting system, Manager Plus or if of an urgent nature a verbal report shall be made immediately.
2. Immediate notification of deficiency was made to Karen Roberts, Maintenance. Maintenance on site to determine that a complete replacement was needed. Full repair was completed by outside contractor on 12/19/18.
3. To prevent reoccurrence of this issue the Operations Director shall utilize the state issued self-inspection form as outlined in regulations noting any deficiencies as well as the bi-annual internal facility inspection report. Deficiencies noted will be recorded and submitted for installation or repair to the maintenance department. Any issues noted to be a potential hazard shall be reported and rectified immediately.
4. Operations Directors/Program Specialists shall complete the stated forms, with monitoring and approval provided by the Regional Director, the forms shall be completed as outlined reviewed by the Operations Director/Regional Director. Any instances of noncompliance shall be logged into the Manager Plus system used by agency maintenance personnel or in instances of a potential hazard notification shall be made via telephone with resolution (either situation made safe or repaired) expected immediately. |
12/19/2018
| Implemented |
| 6400.81(k)(6) | Individual #1 did not have a mirror in his bedroom. | In bedrooms, each individual shall have the following: A mirror. | 1. The provider will ensure that all physical aspects of the home are in good repair by completing the residential facility inspection on a biannual basis in June and December as well as routine checks of the site by all staff and completion of the provider self-inspection as outlined in regulation. Needed repairs are to be reported through the internal online maintenance reporting system, Manager Plus or if of an urgent nature a verbal report shall be made immediately.
2. Immediate notification of deficiency was made to Karen Roberts, Maintenance. Maintenance on site the following week to install the mirror that was in the home. Full installation was completed by 10/23/2018.
3. To prevent reoccurrence of this issue the Site Supervisor/Program Specialist shall utilize the state issued self-inspection form as outlined in regulations noting any deficiencies as well as the bi-annual internal facility inspection report. Deficiencies noted will be recorded and submitted for installation or repair to the maintenance department. Any issues noted to be a potential hazard shall be reported and rectified immediately.
4. Operations Directors/Program Specialists shall complete the stated forms, with monitoring and approval provided by the Regional Director, the forms shall be completed as outlined and reviewed by the Operations Director/Regional Director. Any instances of noncompliance shall be logged into the Manager Plus system used by agency maintenance personnel or in instances of a potential hazard notification shall be made via telephone with resolution (either situation made safe or repaired) expected immediately. |
10/23/2018
| Implemented |