| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.67(a) | The chairs in the common area are damaged and need repaired and/or replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | All chairs that were damaged and in disrepair have been removed and replaced with new chairs and recliners. |
01/16/2024
| Implemented |
| 2380.70(d) | The first aid kit did not contain an operable thermometer. (Corrected at time of inspection) | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | An operable thermometer was placed in the First Aid kit at the time of inspection. |
11/17/2023
| Implemented |
| 2380.89(d) | The fire drill dated 09/27/2023 was timed as 3:27 minutes that the individuals evacuated the facility which exceeded the required 2 ½ minutes. No extended evacuation time was given. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | The Center Director will have a fire safety expert review evacuation of the center and determine the appropriate amount of time needed to safely evacuate. The Fire Safety Expert will provide, in writing, the timeframe which is acceptable to evacuate. The fire safety expert will conduct these drills yearly and submit in writing any altered times. |
01/26/2024
| Implemented |
| 2380.91(a) | Individual #4 and Individual #3 did not have fire safety training in their record at the time of inspection. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | Fire safety training is conducted quarterly based on the more stringent regulations of the PA department of Aging. All members are trained quarterly regardless of overseeing regulatory body. Records of these trainings are kept in the member's chart in the quarterly nursing assessment. |
11/17/2023
| Implemented |
| 2380.111(c)(10) | Individual #3 physical dated 5/24/23 did not indicate information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical form was sent back to the physician to complete the section asking for information pertinent to diagnosis and treatment in case of an emergency. |
02/02/2024
| Implemented |
| 2380.181(e)(5) | Individual #4 assessment dated 9/15/23 indicated that he was able to self-administer medications, however the questions below regarding specific abilities in medication administration all indicate that the individual cannot self-administer. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Program Specialist was educated to the error and instructed to verify the information regarding an individual's ability to self-administer medications with the center nurse prior to completing the assessment. Program Specialist was also instructed to proof read all documents prior to completion. |
01/23/2024
| Implemented |
| 2380.181(e)(12) | Individual #3 assessment dated 11/07/23 did not make recommendations for future training. Being that this is the initial assessment for individuals' recommendations are required.
Individual #4 annual assessment dated 9/15/23 did not make recommendations for future training. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Program Specialist was retrained to the area of the initial assessment indicating recommendations for areas of training, vocational programming, and competitive community-integrated employment. Program Specialist will now indicate in this section whether the member is seeking training or employment. |
01/29/2024
| Implemented |
| 2380.125(b) | Medication DIPHENOXYLATE was in the medication box for Individual #1 that expired 12/15/2022.
Medication EYE DROPS expired 01/2023 for Individual #2 that was in the individual's med box. | A prescription order shall be kept current. | Regional Nurse discussed with center Nurse the importance of reviewing medication expiration dates monthly. |
11/22/2023
| Implemented |
| 2380.126(a)(13) | The medication EYE DROP was signed as administered on individual #2 MAR which states she self-medicates however the medication was not administered on site. It could not be determined if the medication was administered as indicated on the MAR at the facility. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Center Nurse and all staff who administer medications, were trained by Regional Nurse on how to appropriately document on MAR for self-administered medications. |
11/22/2023
| Implemented |
| 2380.129(d) | The Annual Practicum for both Staff #1 and Staff #2 was not completed. As of today, the above staff is not permitted to administer medication until training is completed. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | The Center Director reached out to the Regional Director (Train the Trainer) notifying her that the observation form was signed and dated in the wrong place on the form. Form was corrected. |
11/27/2023
| Implemented |