| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | PA criminal history check was not provided for several new hires. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| 1. All staff will have a completed PA criminal history check within 5 working days after the person's date of hire.
2. No employee will be permitted to begin employment without PA criminal history check. |
10/31/2022
| Implemented |
| 6400.64(a) | The oven and hood vent was dirty with a substance consistent with food residue and grease. | Clean and sanitary conditions shall be maintained in the home. | 1. The grease on around the oven and hood range was cleaned and removed. (Attachments 12 and 13) |
10/31/2022
| Implemented |
| 6400.64(f) | The right most outdoor trash can when facing the trash cans from the side entrance of the home did not have a lid. Trash bags overflowed the can and there was one bag on the ground. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | 1. The outdoor trashcan was replaced on 9/5/2022 (see attachment # 17) |
10/31/2022
| Implemented |
| 6400.80(b) | The fence gate was leaning up against the fence outside and not attached. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 1. The fence was repaired on 9/22/22 by our Maintenance Team and a new fence was replaced (see attachment # 18) |
10/31/2022
| Implemented |
| 6400.141(c)(4) | Individual #3's file does not contain records of a recent hearing screening. Their 11/5/21 physical does not indicate one was completed; an assessment indicated one was completed on 4/9/21, but medical documentation of that screening was requested and not provided. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 1. An appointment for individual #3 is scheduled for 9/28/22. (Attachment # 19) |
10/31/2022
| Implemented |
| 6400.141(c)(6) | Individual #3's two most recent TB tests were greater than two years apart, dated 9/3/19 and 11/19/21. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | 1. A new tool to assist the Health and Wellness Administrators to track medical appointments was created (Attachment #20) |
10/31/2022
| Implemented |
| 6400.141(c)(11) | Individual #3's 11/5/21 physical did not contain an assessment of their health maintenance needs; that section was blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 1. Individual #3 physical was corrected by the doctor on 9/20/22, to ensure compliance. (attachments # 21 and 22l) |
10/31/2022
| Implemented |
| 6400.142(a) | Individual #3 has not had a dental exam since 6/30/21. Exam documentation from within the past year was requested but not provided. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | 1. Individual #3 is scheduled for a dental appointment on 12/19/2022. (attachment # 23) |
10/31/2022
| Implemented |
| 6400.144 | Medical follow-ups are not being completed as ordered for Individual #3. An 11/2/21 podiatry visit medical document called for a follow-up visit within two weeks. Documentation that the follow-up was completed was requested but not provided. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 1. Individual #3 podiatry appointment was scheduled for 10/11/22, to ensure compliance. (Attachment #24) |
10/31/2022
| Implemented |
| 6400.24 | FBI checks not provided for the employees that have not lived in PA for 2 consecutive years. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | 1. FBI checks will be scheduled by HR Recruiter and verified Human Resource Administrator.
2. No employee will be permitted to work employment without FBI checks that have not lived in PA for 2 consecutive years. |
10/31/2022
| Implemented |
| 6400.32(r) | There were no locks on Individual #3 and Individual #4's bedrooms. The doors did not have an ability to be locked for privacy. | An individual has the right to lock the individual's bedroom door. | 1. Doorknobs have been changed to have locking capability on Individual #3 & #4 on 9/9/2022. (Attachments #1 and 2) |
10/31/2022
| Implemented |
| 6400.50(b) | The form used for tracking annual staff training hours contained inaccuracies. The times and dates of trainings were inconsistent with the certificates provided. | The home shall keep a training record for each person trained. | 1. The Human Resource Compliance Generalist is developing a routine audit checklist for all the staff training records/hours to ensure regulatory compliance. |
10/31/2022
| Implemented |
| 6400.165(c) | The medication Calcium 600mg tablet with Vitamin D3 to be given twice daily to individual #3 at 8am and 5pm was not being administered as prescribed. | A prescription medication shall be administered as prescribed. | 1. The Direct Support Professionals working in the home are scheduled to attend a Medication Administration Training completed by a certified medication trainer on 9/30/2022. |
10/31/2022
| Implemented |
| 6400.166(b) | The medication Calcium 600mg tablet with Vitamin D3 to be given twice daily to individual #3 at 8am and 5pm was not being logged properly after or lack of administration. The medication was logged as given at 8am when none was available August 1-3rd 2022. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | 1. The Direct Support Professionals working in the home are scheduled to attend a Medication Administration Training completed by a certified medication trainer on 9/30/2022. |
10/31/2022
| Implemented |
| 6400.166(d) | The directions to give Calcium 600mg tablet with Vitamin D3 to be given twice daily to individual #3 at 8am and 5pm were not being followed. The log provided only documented one administration time. | The directions of the prescriber shall be followed. | 1. The Direct Support Professionals working in the home are scheduled to attend a Medication Administration Training completed by a certified medication trainer on 9/30/2022. |
10/31/2022
| Implemented |