| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(e) | The large trashcan in the downstairs bathroom did not have a lid on it. | Trash receptacles over 18 inches high shall have lids. | The large trash can in the downstairs bathroom was replaced. See Attachment #30 |
10/26/2017
| Implemented |
| 6400.66 | The side door exit did not have an exterior light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A work order was completed and installation of light will be completed. See Attachment #29 |
11/10/2017
| Implemented |
| 6400.74 | Approximately 5 exterior steps leading out of the side door were not equipped with a non skid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Non-skid strips were applied to concrete steps on 10/26/17. See Attachment #28 |
10/26/2017
| Implemented |
| 6400.110(a) | The smoke detector in the attic was not operable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The smoke detector in the attic is operable. When tested with canned smoke (most recently 10/26/17) it activated the entire system. There is not an auditory alarm in the attic detector, but the auditory alarms elsewhere in the home are clearly audible in the attic |
10/26/2017
| Implemented |
| 6400.145(3) | The home's emergency medical plan did not include emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | The home's written emergency medical plan was updated on 10/16/17 to include an emergency staff plan. See Attachment #14 |
10/16/2017
| Implemented |
| 6400.151(c)(2) | REPEAT from 12/14/16 renewal inspection: Staff #3's date of hire was 6/5/17 and he did not have his Tuberculin skin test read until 6/7/17. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The employee in question has resigned and all new employees must now complete their physical examination including their TB test prior to the first date of hire. See Attachment #27. |
09/27/2017
| Implemented |
| 6400.168(a) | Staff #3's date of hire was 6/5/17 and he has been passing medications. However his initial medication administration training was never completed, signed, or dated by a medication trainer. All sections were left blank. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | An initial medication administration training sheet has been completed by certified medication trainers of recently hired new employee. See Attachment #23.
The executive director trained current medication supervisors on 10/30/17 on regulation 168 (a) that medication trainers must complete initial medication training sheets and annual practicums in their entirety according to medication policy and procedures, DPW Medication Administration Training and ODP state regulations. See Attachment #24. |
10/30/2017
| Implemented |
| 6400.168(b) | Staff #6 had been administering insulin injections over the passed year however her insulin injection training was late; 6/23/16 and not again until 7/5/17. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course and who has completed and passed a diabetes patient education program within the past 12 months that meets the National Standards for Diabetes Patient Education Programs of the National Diabetes Advisory Board, 7550 Wisconsin Avenue, Bethesda, Maryland 20205, is permitted to administer insulin injections to an individual who is under the care of a licensed physician who is monitoring the diabetes, if insulin is premeasured by licensed or certified medical personnel. | The Executive Director trained Program Specialists and Supervisors on regulation 168(b) to insure staff are scheduled prior to required deadlines for all medication administration training including insulin injection training that must complete and pass a diabetes patient education program within the past 12 months. |
10/30/2017
| Implemented |
| 6400.168(c) | Staff #4's medication administration training was signed off as being certified on 4/17/17 by Staff #5. However Staff #5's medication administration trainer certificate expired on 4/15/17 with no record of an extension granted. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | Staff #4 received initial training on 04/11/17 and 04/12/17 when Staff #5's certification was still valid. Training has been set for Staff #4 to receive training from a certified trainer to demonstrate medication passes on 11/01/17. See attachments #26a, 26b, 26c, 26d and 26e.
The executive director reviewed with the medication trainers that certifications must be kept current according to policy and regulation. See Attachment #24. |
11/01/2017
| Implemented |
| 6400.216(a) | Individuals' records were unlocked and accessible in the closet and white cabinet in the basement. Individuals' programming record books were left unlocked and accessible in the staff room. The records were not able to be locked in the staff room because there wasn't a door on the staff room. | An individual's records shall be kept locked when unattended. | A training memo was created and sent to direct support professionals indicating the regulation of all individuals records need to be locked when not attended. An individual record shall be kept locked when unattended. The individual and the individual's parent, guardian or advocate shall have access to the records and to information in the records. If the interdisciplinary team documents that disclosure of specific information constitutes a substantial detriment to the individual or that disclosure of specific information will reveal the identity of another individual or breach the confidentiality of persons who have provided information upon an agreement to maintain their confidentiality, that specific information identified may be withheld. See Attachment #22 |
10/30/2017
| Implemented |
| Article X.1007 | REAPEAT from 12/14/16 renewal inspection: Cambria Residential Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1's date of hire was 3/7/17 and her criminal history record check was completed more than a year prior to her employment. Her record check was completed on 11/2/15. Staff #2 was hired on 5/31/17 and his criminal history record check was not completed until 6/5/17. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | No employee will be permitted to attend a training class or start work without having submitted an acceptable Criminal Record Check. See Attachment #31 |
09/27/2017
| Implemented |