Subchapter C. LICENSING
TYPE OF CERTIFICATE OF COMPLIANCE Sec.
6000.301. Certificate of compliance determination.
COMMUNITY RESIDENTIAL MENTAL RETARDATION
FACILITIES AND AGENCIES
6000.302. Computation of weighted score.
6000.303. No license factors.
6000.304. Provisional license factors.
VOCATIONAL FACILITIES
6000.311. Computation of weighted score.
6000.312. No license factors.
6000.313. Provisional license factors.
ADULT DAY CARE CENTERS
6000.321.hc Computation of percentage of compliance.
6000.322. No license factors.
6000.323. Provisional license factors.
REQUIREMENTS FOR ALL TYPES OF FACILITIES AND AGENCIES
6000.331. Repeated noncompliance areas.
6000.332. Recommendation variance.
LICENSED/APPROVED CAPACITY
6000.341. Capacity.
6000.342. Indoor floor space.
LICENSURE OF COMMUNITY RESIDENTIAL MENTAL
RETARDATION FACILITIES
6000.351. Licensing criteria.
LICENSURE OF ADULT DAY CARE CENTERS
LOCATED IN NURSING HOMES
6000.361. Adult day care centers in a nursing home.
DUAL LICENSURE OF ADULT DAY CARE CENTERS
AND VOCATIONAL REHABILITATION FACILITIES
6000.371. Dual licensure.
Source The provisions of this Subchapter C adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3703, unless otherwise noted.
TYPE OF CERTIFICATE OF COMPLIANCE
§ 6000.301. Certificate of compliance determination.
The type of certificate of compliance indicated is determined by the type of noncompliance areas, the total weighted score for vocational and community residential mental retardation facilities, the percentage of compliance with the licensing regulations for adult day care centers and the number of repeated areas of noncompliance.
COMMUNITY RESIDENTIAL MENTAL
RETARDATION FACILITIES AND AGENCIES
§ 6000.302. Computation of weighted score.
(a) The total weighted score for each facility shall be computed according to the instructions in the licensing inspection instrument. The individual weights for each licensing inspection instrument item are listed in Appendix A.
(b) The distribution of the weighted scores used to determine the type of license to be issued is as follows:
(1) Score of 100 through 65 = Regular license.
(2) Score of 64 through 43 = Provisional license.
(3) Score of 42 and below = No license.
§ 6000.303. No license factors.
If there is noncompliance with either of the following two sections at the time the license is to be issued, no license will be issued:
(1) Section 6400.13 (relating to maximum capacity)—first sentence. This is a no license regulation for new facilities and for facilities with no occupancy permit.
(2) Section 6400.18 (relating to reporting of unusual incidents). Each incidence of abuse will be investigated and evaluated individually by the Office of Mental Retardation before any negative licensing action is taken.
§ 6000.304. Provisional license factors.
If there is noncompliance with any one of the following sections at the time the license is issued, a provisional license is indicated:
(1) Section 6400.13 (relating to maximum capacity)—first sentence. This is a provisional regulation for existing facilities that have an occupancy permit, but the occupancy classification is not correct.
(2) Section 6400.45 (relating to staff).
(3) Section 6400.46(a) and (b) (relating to staff training).
(4) Section 6400.103 (relating to evacuation procedures).
(5) Section 6400.105 (relating to flammable and combustible materials).
(6) Section 6400.133 (Reserved).
(7) Section 6400.136 (Reserved).
(8) Section 6400.156 (Reserved).
VOCATIONAL FACILITIES
§ 6000.311. Computation of weighted score.
(a) The total weighted score shall be computed according to the instructions in the licensing inspection instrument. The individual weights for each item are listed in Appendix B:
(b) The distribution of weighted scores used to determine the type of license to be issued is as follows:
(1) Score of 100 through 70 = Regular license.
(2) Score of 69 through 52 = Provisional license.
(3) Score of 51 and below = no license.
§ 6000.312. No license factors.
(a) Compliance with certain sections with a weight of 8 or above is so critical that if there is noncompliance with that section or subsection a regular license cannot be issued.
(b) If there is noncompliance with either of the following sections at the time the license is to be issued, no license will be issued:
(1) Section 2390.14(a) (relating to fire safety occupancy permit)—weight 8.33. This is a no license regulation for new facilities and facilities with no occupancy permit.
(2) Section 2390.19(a) (relating to abuse)—weight 8.81. Each incidence of abuse will be investigated and evaluated individually by the Office of Mental Retardation before negative licensing action is taken.
§ 6000.313. Provisional license factors.
If there is noncompliance with any of the following sections at the time the license is issued, a provisional license is indicated:
(1) Section 2390.14(a) (relating to fire safety occupancy permit)—weight 8.33. This is a provisional regulation for existing facilities that have an occupancy permit, but the occupancy classification is not correct.
(2) Section 2390.19 (relating to abuse).
(i) Subsection (b)—weight 8.64.
(ii) Subsection (c)—weight 8.60.
(iii) Subsection (d)—weight 8.76.
(3) Section 2390.53 (relating to outside walkways)—weight 8.17.
(4) Section 2390.54 (relating to combustible materials)—weight 8.59.
(5) Section 2390.63 (relating to lighting)—weight 8.06.
(6) Section 2390.64 (relating to handrails)—weight 8.06.
(7) Section 2390.68 (relating to hazardous equipment)—weight 8.64.
(8) Section 2390.69 (relating to personal protective equipment)—weight 8.65.
(9) Section 2390.70 (relating to special signals on equipment)—weight 8.13.
(10) Section 2390.71(b) (relating to ventilation)—weight 8.49.
(11) Section 2390.75 (relating to nutrition).
(i) Subsection (a)(1)—weight 8.37.
(ii) Subsection (a)(2)—weight 8.17.
(12) Section 2390.81 (relating to exits)—weight 8.42.
(13) Section 2390.83 (relating to fire alarms)—weight 8.56.
(14) Section 2390.84 (relating to fire extinguishers).
(i) Subsection (a)—weight 8.14.
(ii) Subsection (c)—weight 8.24.
(iii) Subsection (f)—weight 8.14.
(iv) Subsection (g)—weight 8.04.
(15) Section 2390.101 (relating to communicable disease)—weight 8.37.
(16 ) Section 2390.102 (relating to first aid staff)—weight 8.15.
(17) Section 2390.104 (relating to emergency medical information)—weight 8.32.
ADULT DAY CARE CENTERS
§ 6000.321. Computation of percentage of compliance.
(a) If there is 95% compliance or above, a regular certificate is indicated.
(b) If there is greater than or equal to 85% but less than 95% compliance, a provisional certificate is indicated.
(c) If compliance is below 85%, no certificate is indicated.
§ 6000.322. No license factors.
If there is noncompliance with § 2380.13 (relating to maximum capacity) at the time the license is to be issued, no license can be issued.
§ 6000.323. Provisional license factors.
If there is noncompliance with any of the following sections at the time the license is issued, a provisional license is indicated:
(1) Section 2380.25 (Reserved).
(2) Section 2380.41 (Reserved).
REQUIREMENTS FOR ALL TYPES
OF FACILITIES AND AGENCIES
§ 6000.331. Repeated noncompliance areas.
(1) Repeated noncompliance areas are determined based on the previous annual, provisional or interim—announced and unannounced—inspections.
(2) Repeated noncompliance areas are determined based on areas of noncompliance observed during the previous initial licensing inspection, and not at the time the previous license was issued.
(3) If there are one, two or three repeated noncompliance areas—regardless of weight—from the previous licensing inspection to the present licensing inspection, a provisional certificate is indicated.
(4) If there are four or more repeated noncompliance areas—regardless of weight—from the previous licensing inspection to the present licensing inspection, no certificate is indicated.
(5) If there are one or more repeated noncompliance areas—regardless of weight—in three or more consecutive annual, provisional or interim licensing inspections, no certificate is indicated.
(6) For community residential agencies, if the same noncompliance area at one facility is repeated at a different facility operated by the same community residential agency during the next inspection, this is considered a repeated noncompliance area.
(7) Physical site noncompliance areas under § § 2380.61 and 6400.76 (relating to telephone; and furniture and equipment) are not considered repeated noncompliance areas if the specific object or condition cited for repair differs from the previous inspection. For example, if a doorknob is missing 1 year and the next year the paint is cracked and peeling, this is not repeated noncompliance. If there is cracked, peeling paint cited in two consecutive inspections—even in different community residential agency facilities—this is repeated noncompliance.
§ 6000.332. Recommendation variance.
(a) The weighting and percentage of compliance systems are guidelines used to determine the type of licensing to be issued. It is recognized that in special circumstances these standardized scoring systems may not be in the best interests of the clients and that professional discretion must be exercised.
(b) The policies and procedures for the type of certificate of compliance should be the basis for the licensure recommendation. If the Regional Mental Retardation Program Manager disagrees with the type of certificate to be issued based on this chapter, the Regional Mental Retardation Program Manager may make a recommendation that differs from these policies and procedures. If the Regional Mental Retardation Program Manager makes a recommendation for licensure that is inconsistent with the manual instructions, detailed written justification for the variance from the Regional Mental Retardation Program Manager will accompany the licensure packet.
LICENSED/APPROVED CAPACITY
§ 6000.341. Capacity.
(a) Licensed/approved capacity is defined as the maximum number of clients or residents who may be served at a facility at any one time. The licensed/approved capacity appears on a certificate of compliance. Capacity is based on the amount of available indoor floor space at the facility. Compliance with all other licensing regulations is measured by onsite observation, record review and interviews. Compliance with staffing ratios is measured by actual attendance on any given day.
(b) Licensed/approved capacity does not mean that the facility currently meets all the staffing requirements necessary for that number of clients. Licensed/approved capacity means only that the facility may serve up to the specified number of clients as determined by the application of minimum floor space requirements. The actual number of clients served depends on the facility meeting staffing and other regulations.
(c) The capacity of a facility will be increased or decreased only in the following instances:
(1) There is renovation or construction of the facility which changes the amount of indoor floor space.
(2) There is reallocation of the indoor space.
(3) There was an error in the previous calculation of the amount of indoor floor space.
(d) The licensed/approved capacity of a currently licensed/approved facility will be adjusted, if necessary, according to this statement of policy in either of the following instances:
(1) When the facility’s next renewal certificate of compliance is issued.
(2) If a facility requests that its capacity be adjusted according to this statement of policy prior to their current certificate expiration, a new certificate adjusting the capacity will be issued at this time.
§ 6000.342. Indoor floor space.
The minimum amount of indoor floor space required for facilities is specified in the appropriate chapter of licensing regulations and further clarified in the corresponding licensing inspection instrument.
(1) Community Residential Mental Retardation Facilities—§ § 6400.85(b) and 6400.232 (relating to swimming pools; and awake staff persons) and corresponding sections of the Licensing Inspection Instrument. In addition to the amount of indoor floor space, the licensed/approved capacity for community residential facilities shall also be based upon the type of fire safety approval that the facility has. The licensed/approved capacity shall be based upon the amount of indoor floor space not to exceed the occupancy limit of the facility’s current fire safety approval. For example, if a facility has indoor floor space for 12 residents, but the facility has only a C-3 Certificate of Occupancy from the Department of Labor and Industry which limits occupancy to eight residents, the licensed/approved capacity will be eight.
(2) Adult Day Care Centers—§ 2380.61 (relating to minimum amount of space) and corresponding section of the licensing inspection instrument. For the adult day care centers, indoor floor space is measured wall to wall, including space occupied by furniture. Hallways and offices are not counted when measuring indoor floor space. Dining areas, kitchens, bathrooms and first aid rooms are counted when measuring indoor floor space if it is clearly documented that the area is used for program purposes for at least 50% of each program day or if it is clearly documented in the facility’s training curriculum that the area is used as an integral part of their training program.
(3) Vocational Facilities—§ 2390.52 (relating to indoor floor space) and corresponding sections of the licensing inspection instrument.
LICENSURE OF COMMUNITY RESIDENTIAL
MENTAL RETARDATION FACILITIES
§ 6000.351. Licensing criteria.
(a) The following criteria should be applied to determine if a facility should be licensed under Chapter 6400 (relating to community homes for individuals with mental retardation).
(1) If a facility meets either of the following criteria, the facility is considered a community residential facility and shall comply with Chapter 6400:
(i) The facility is leased or owned by the provider agency or County MH/MR Program. The resident does not sign his own lease or own his own home.
(ii) An average of more than 10 hours of direct staff contact per week is provided to the facility. Staff may or may not live within the same apartment building or complex.
(2) Direct staff contact includes person to person contact spent in training, programming and assisting the resident with daily living skills. It does not include telephone contact and time spent providing transportation to residents.
(3) Licensing staff should review written leases and staffing schedules to determine if the criteria in this section apply to a specific individual facility. Following is a matrix that may be helpful in determining applicability of the regulations for a specific facility.
If more than 10 hours of direct staff contact per week per facility If 10 hours or less direct staff per week per facility If all residents sign their own lease without agency co-signature or own their own home LICENSE DO NOT LICENSE If agency signs lease or owns building; or if agency co-signs lease with resident LICENSE LICENSE
LICENSURE OF ADULT DAY CARE CENTERS
LOCATED IN NURSING HOMES
§ 6000.361. Adult day care centers located in a nursing home.
(a) If an adult day care center located in a nursing home serves only nursing home clients, the Department should not license the adult day care center.
(b) If an adult day care center located in a nursing home serves one or more public clients (nonnursing home clients), with at least a total of four clients, the Department should license the adult day care center using the following procedures:
(1) The inspector asks the provider or inspects the facility to determine if the facility has a current License to Operate a Health Care Facility issued by the Department of Health. This license covers both skilled and intermediate nursing homes. This license should be posted in a conspicuous place in the facility.
(2) If the facility has a current Department of Health license, the provider shall acquire a letter from the Department of Health stating that specific space within the nursing home building may be utilized for adult day care.
(3) If the provider produces a letter from the Department of Health stating that specific space may be used for adult day care, standard procedures should be followed.
(4) If the provider cannot produce a letter from the Department of Health stating that space may be used for adult day care, the Department of Human Services cannot license the facility for adult day care and the facility may not provide adult day care to nonnursing home clients.
DUAL LICENSURE OF ADULT DAY CARE
CENTERS AND VOCATIONAL
REHABILITATION FACILITIES
§ 6000.371. Dual licensure.
(a) A facility should be licensed under both adult day care center and vocational facility regulations if the regulatory definitions of both sets of regulations are met. The main regulatory distinction between an adult day care center and a vocational facility is that an adult day care center, less than 20% of the client’s programming is comprised of remunerative work experience. In a vocational facility, 20% or more of the client’s programming is comprised of remunerative work experience. The average percentage of remunerative work experience provided to each client over a 12-month period will be considered in this determination.
(b) If both adult day care center and vocational facility definitions are met, the following dual licensure procedures apply.
(1) Adult day care clients and vocational clients must be served in separate and distinct program areas or groups within the facility. Nonprogram areas such as bathrooms and dining areas can be shared.
(2) Apply both sets of regulations, completing two separate licensing inspection instrument scoresheets and two licensing inspection instruments.
(3) Apply adult day care and vocational regulations separately. For example, apply 1:7 ratio adult day care clients and 1:15 or 1:20 ratio for vocational facility clients.
(4) Issue two separate certificates. It is possible that the adult day care center could receive a regular certificate and the vocational facility could receive a provisional certificate.
(5) The facility will appear on licensing printouts as both an adult day care center and a vocational facility.
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