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GENERAL PROVISIONSInspections and Licenses3c2600.3(c) - The personal care home shall post the current license, a copy of the current licensinginspection summary issued by the Department and a copy of this chapter in a conspicuous andpublic place in the personal care home.Discussion: A “licensing inspection summary” is the Violation Report (VR) with a plan of correction approved bythe Department. The Department interprets ‘most current version’ to mean: The VR that was issued with the most current license, and Any additional VRs issued between the most current license and the receipt of the next license.If there is no VR since there are no violations, the VR does not need to be posted. A “copy of this chapter” meansthe “pink book,” 55 Pa.Code § 2600.These items must be displayed in a public area of the home, such as a public bulletin board in the home’s entryway,in a manner easily visible and accessible to all residents and visitors.Inspection Procedures: Inspectors will view the area where the required items are posted to determine if theyare accessible to all residents and guests without assistance from staff.Primary Benefit: Permits residents, families, and visitors to learn about applicable regulations and the regulatorycompliance status of the home and the home’s plan to correct any violations found.Access5a12600.5(a)(1) - The administrator or a designee shall provide, upon request, immediate access tothe home, the residents and records to: Agents of the Department.Discussion: An agent of the Department is any individual authorized by the Department to enter, visit, inspect, orinvestigate regulatory issues in personal care homes. In the case of access to residents who are not currently atthe home, access should be granted as soon the resident can return to the home. Access must be provided to allareas of any building accessible to residents and to areas where harmful materials may be stored.Resident records must be kept on site; other records may be kept off-site as long as such storage permitsimmediate access regardless of the day or time of the request.Inspection Procedures: “Immediate” means a reasonable period of time depending on the request. Forexample, it’s reasonable to expect a home to produce a resident’s support plan within 10 minutes during regularbusiness hours, but unreasonable to expect off-site staff records to be delivered within 10 minutes at 2:00 AM.Primary Benefit: Allows the Department to measure compliance with all regulations.5a22600.5(a)(2) - The administrator or a designee shall provide, upon request, immediate access tothe home, the residents and records to: Representatives of the area agency on aging.Discussion: A representative of the area agency on aging is any individual authorized by the area agency on agingto enter, investigate, or provide services in personal care homes. In the case of access to residents who are notcurrently at the home, access should be granted as soon the resident can return to the home. Access must beprovided to all areas of any building accessible to residents and to areas where harmful materials may be stored.Resident records must be kept on site; other records may be kept off-site as long as such storage permitsimmediate access regardless of the day or time of the request.Inspection Procedures: “Immediate” means a reasonable period of time depending on the request. Forexample, it’s reasonable to expect a home to produce a resident’s support plan within 10 minutes during regularbusiness hours, but unreasonable to expect off-site staff records to be delivered within 10 minutes at 2:00 AM.Primary Benefit: Allows area agency on aging the ability to fulfill their legal mandate to protect older adults.10

5a32600.5(a)(3) - The administrator or a designee shall provide, upon request, immediate access tothe home, the residents and records to: Representatives of the Long-Term Care OmbudsmanProgram.Discussion: A representative of the Long-Term Care Ombudsman Program is any individual authorized by theLong-Term Care Ombudsman Program to enter, investigate, or provide services in personal care homes. In thecase of access to residents who are not currently at the home, access should be granted as soon the resident canreturn to the home. Access must be provided to all areas of any building accessible to residents and to areas whereharmful materials may be stored.Resident records must be kept on site; other records may be kept off-site as long as such storage permitsimmediate access regardless of the day or time of the request.Inspection Procedures: “Immediate” means a reasonable period of time depending on the request. Forexample, it’s reasonable to expect a home to produce a resident’s support plan within 10 minutes during regularbusiness hours, but unreasonable to expect off-site staff records to be delivered within 10 minutes at 2:00 AM.Primary Benefit: Provides ombudsmen with the access necessary to promote and protect resident rights.5a42600.5(a)(4) - The administrator or a designee shall provide, upon request, immediate access tothe home, the residents and records to: Representatives of the protection and advocacy system forindividuals with disabilities designated under the Protection and Advocacy for Individual RightsProgram of the Vocational Rehabilitation and Rehabilitation Services Act (29 U.S.C.A. § 794e), theProtection and Advocacy for Individuals with Mental Illness Act (42 U.S.C.A. § 10801-10851), andthe Developmental Disabilities Assistance and Bill of rights Act (42 U.S.C.A. § 15041-15043).Discussion: A representative of the protection and advocacy system for individuals with disabilities program is anyindividual authorized by the program to enter, investigate, or provide services in personal care homes. InPennsylvania, this system is currently administered by the Disability Rights Network of Pennsylvania, 1414 CameronStreet, Harrisburg, Pennsylvania 17103-1049, telephone number (717) 236-8110. In the case of access toresidents who are not currently at the home access should be granted as soon the resident can return to the home.Access must be provided to all areas of any building accessible to residents and to areas where harmful materialsmay be stored.Resident records must be kept on site; other records may be kept off-site as long as such storage permitsimmediate access regardless of the day or time of the request.Inspection Procedures: “Immediate” means a reasonable period of time depending on the request. Forexample, it’s reasonable to expect a home to produce a resident’s support plan within 10 minutes during regularbusiness hours, but unreasonable to expect off-site staff records to be delivered within 10 minutes at 2:00 AM.Primary Benefit: Provides advocates with the access necessary to protect the rights of residents with disabilities.5b2600.5(b) - The administrator or a designee shall permit community service organizations andrepresentatives of community legal services programs to have access to the home during visitationhours or by appointment for the purpose of assisting or informing the residents of the availability ofservices and assistance. A resident or a resident’s designated person may decline the services ofthe community service organization or the community legal service program.Discussion: This requirement is closely related to § 2600.222, which requires homes to encourage residents touse social and community services available in the community.Inspection Procedures: Inspectors will interview the administrator, staff of the home, and representatives ofcommunity service organizations who may be present at the home or who file complaints with the Department.Primary Benefit: Allows service organizations to provide information to residents who may benefits from theirservices, and allows the home to ensure compliance with § 2600.222.11

GENERAL REQUIREMENTSProcedural Requirements for Licensure or Approval of Personal Care Homes11a2600.11(a) - Except for § 20.32 (relating to announced inspections), the requirements in Chapter20 (relating to licensure or approval of facilities and agencies) apply to personal care homes.Discussion: Personal care homes are licensed in accordance with the licensing procedures established by 55Pa.Code Chapter 20. Homes are strongly encouraged to review Chapter 20, which is available on the Department’swebsite. Knowledge of Chapter 20 is required by regulation for administrators – see § 2600.53(f).Inspection Procedures: If a violation of Chapter 20 is suspected, inspectors will cite only in consultation with theregional director and ARL headquarters.Primary Benefit: Chapter 20 contains additional regulatory requirements, including the allowable reasons fordenial, revocation, or nonrenewal of a license.Maximum Capacity13b2600.13(b) - The maximum capacity specified on the license may not be exceeded.Discussion: “Maximum capacity” means the total number of residents who require personal care services that thehome is permitted to serve. The maximum capacity is different from the number of people who may reside in ahome as determined by the home’s certificate of occupancy. See “Certificates of Occupancy and MaximumCapacity” in the “Regulatory Issues and Frequently-Occurring Situations” section for more information. Occupantsof the home who do not need personal care services (sometimes referred to as “independent” residents) are notcounted when determining if the home’s maximum capacity has been exceeded. However, because maximumcapacity is determined in part by square footage and by the number of sinks, toilets, and showers in the home, thetotal number of persons living in a home must be considered when determining compliance with other regulations(such as bedroom square footage, number of toilets, and the like).Inspection Procedures: Inspectors will verify the total number of persons who reside in the home. If thenumber of residents who require personal care services exceeds the maximum capacity as specified on the license,a violation exists.Primary Benefit: Protects from overcrowding, and ensures that the number of people living in the home does notexceed toilet, bathing or hand-washing facilities necessary to maintain sanitary conditions.Fire Safety Approval14a2600.14(a) - Prior to issuance of a license, a written fire safety approval from the Department ofLabor and Industry, the Department of Health or the appropriate local building authority under thePennsylvania Construction Code Act (35 P.S. § 7210.101 – 7210.1103) is required.Discussion: Please see “Certificates of Occupancy and Maximum Capacity” in the “Regulatory Issues andFrequently-Occurring Situations” section for more information.Inspection Procedures: Inspectors will review and obtain a copy of the home’s certificate of occupancy duringthe inspection.Primary Benefit: Ensures that the home is appropriately constructed to serve individuals in a residential setting.12

14b2600.14(b) - If the fire safety approval is withdrawn or restricted, the home shall notify theDepartment orally immediately, and in writing, within 48 hours of the withdrawal or restriction.Discussion: A certificate of occupancy may be withdrawn or restricted due to damage, physical site modificationsnot approved by the local building authority, and the like. Withdrawal or restriction will be issued in writing; thiswritten documentation should be provided to the Department with the notification required by this regulation.Inspection Procedures: Inspectors will interview administrator and maintenance staff to determine if the home’scertificate of occupancy has been withdrawn or restricted within the past year or if it is currently restricted.Primary Benefit: Ensures that resident health and safety is not compromised by failure to meet or maintainconstruction standards.14c2600.14(c) - If a building is structurally renovated or altered after the initial fire safety approval isissued, the home shall submit the new fire safety approval, or written certification that a new firesafety approval is not required, from the appropriate fire safety authority. This documentation shallbe submitted to the Department within 15 days of the completion of the renovation or alteration.Discussion: The Uniform Construction Code (UCC) requires a new certificate of occupancy for major structural,electrical, mechanical, and plumbing changes. In the event that a new certificate of occupancy is not required, it isrecommended that a statement from the local building authority or the Department of Labor and Industry indicatingthat a new certificate of occupancy is not required be obtained. Please see “Certificates of Occupancy andMaximum Capacity” in the “Regulatory Issues and Frequently-Occurring Situations” section for more informationabout “major” and “minor” repairs.Inspection Procedures: Minor repairs of most systems do not require new permits. However, major repairs orrenovations may. Inspectors will ask for a new permit or written certification that a new permit is not needed whenmajor repairs, renovations, or new construction has occurred.Primary Benefit: Ensures that resident health and safety is not compromised by failure to meet or maintainconstruction standards.Abuse Reporting Covered by Law15a2600.15(a) - The home shall immediately report suspected abuse of a resident served in the homein accordance with the Older Adults Protective Services Act (35 P.S. Sections 10225.701 –10225.707) and 6 Pa. Code Sections 15.21 – 15.27 (relating to reporting suspected abuse) andcomply with the requirements regarding restrictions on staff persons.Discussion: Please see “Abuse and Abuse Reporting” in “Regulatory Issues and Frequently-Occurring Situations”for more information.Inspection Procedures: Inspectors will verify that the home followed all of the steps as described in the “Abuseand Abuse Reporting” section.Primary Benefit: Ensures that abuse or suspected abuse is appropriately reported and investigated.13

15b2600.15(b) - If there is an allegation of abuse of a resident involving a home’s staff person, thehome shall immediately develop and implement a plan of supervision or suspend the staff personinvolved in the alleged incident.Discussion: Please see “Abuse and Abuse Reporting” in “Regulatory Issues and Frequently-Occurring Situations”for more information.Inspection Procedures:See § 2600.15(a).Primary Benefit: See § 2600.15(a).15c2600.15(c) - The home shall immediately submit to the Department’s personal care home regionaloffice a plan of supervision or notice of suspension of the affected staff person.Discussion: Please see “Abuse and Abuse Reporting” in “Regulatory Issues and Frequently-Occurring Situations”for more information.Inspection Procedures:See § 2600.15(a).Primary Benefit: See § 2600.15(a).15d2600.15(d) - The home shall immediately notify the resident and the resident’s designated personof a report of suspected abuse or neglect involving the resident.Discussion: Please see “Abuse and Abuse Reporting” in “Regulatory Issues and Frequently-Occurring Situations”for more information.Inspection Procedures:See § 2600.15(a).Primary Benefit: See § 2600.15(a).Reportable Incidents and Conditions16b2600.16(b) - The home shall develop and implement written policies and procedures on theprevention, reporting, notification, investigation and management of reportable incidents andconditions.Discussion: There is no requirement for the content of these policies and procedures beyond what is explained indetail below in § 2600.16(c)-(f). However, it is recommended that homes include the following information: Prevention – How will the home identify and keep each type of incident from happening?o Prevention methods will vary by incident type (such as a utility shut-off notice versus a fire); it isrecommended that prevention policies are developed for each type of incident. Prevention policiesfor incidents with similar prevention methods may be combined. Reporting - How will incidents be reported to the administrator? Notification - Who is responsible for notification to the Department and applicable agencies, and what is themethod by which they will make the notification (fax, phone; etc.)? Investigation – What is the method and who is the person responsible for investigating the incident? Management – How will the reportable incident be recorded and stored, and how trends will be tracked?Please see Appendix A for a list of reportable incidents and events that homes are not required to report.Inspection Procedures: Inspectors will review the policies and procedures to verify that all of the contentrequired by this regulation is addressed. If a violation of § 2600.16(c) is identified, inspectors will compare theviolation with the home’s written policies to determine whether the policy was followed and/or if a modification tothe process is required.Primary Benefit: Robust policies and procedures ensures that the home is accurately managing reportableincidents, tracking patterns of incidents, and taking steps to prevent future incidents.14

16c2600.16(c) - The home shall report the incident or condition to the Department’s personal carehome regional office or the personal care home complaint hotline within 24 hours in a mannerdesignated by the Department. Abuse reporting shall also follow the guidelines in § 2600.15(relating to abuse reporting covered by law).Discussion: When it comes to reportable incidents, the more specific information a home can provide about theincident, including a timeline of events, actions taken by the home in response to the event, and the home’s plansto prevent similar incidents in the future, demonstrates the home’s commitment to regulatory compliance and mayreduce the need for the Department to pursue additional information. Please see Appendix A for a list of reportableincidents.Homes should never downplay or minimize the details in an incident report. There have been instances whereincidents with scant details proved to be quite serious, which may suggest a deliberate attempt to withholdinformation – which is usually not the case!Homes frequently ask whether a certain type of event or specific situation needs to be reported. It is recommendedthat homes follow the “when in doubt, send it out” rule: if you have to ask, you should probably send the report.There is no violation for reporting incidents or conditions beyond what is required. However, some events onlyneed to be reported if certain conditions apply: Personal care homes are required to report any “serious bodily injury or trauma requiring treatment at ahospital or medical facility.” The Department interprets “serious bodily injury or trauma” to mean anyinjury where the resident experienced one or more of the following:Substa

2600.3(c) - The personal care home shall post the current license, a copy of the current licensing inspection summary issued by the Department and a copy of this chapter in a conspicuous and public place in the personal care home. Discussion: A “licensing inspection summary” is the Vi