| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.73 | REPEAT violation from 5/14/19 annual inspection: The stairway steps (more than two steps) leading from the first floor of the home to the basement, is not equipped with a well-secured handrail | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | Staff #1 and Lifesharing Specialist were retrained on Regulation 6500.73 on 8/27/2020, attachment #11. A handrail was installed on the stairs leading from the first floor to the basement on 8/30/2020, attachment #12. A monthly home visit will be completed by the Lifesharing Specialist for as long as the individual is enrolled in Lifesharing Services, to ensure well secured handrails are installed at all stairways with 2 or more steps. A Household Check list will be completed at each monthly home visit and distributed to Residential Director or designee. |
08/30/2020
| Not Implemented |
| 6500.110(a) | The fire safety training plan developed for the home is not current and includes individuals, Family member #2, who no longer reside in the home. | A written fire safety training plan shall be developed for all family members and individuals including children. | A home visit was completed on 8/27/2020 that included an updated fire safety training plan, for Individual #1 & Staff #1, attachment #39. The fire safety training plan no longer includes Family Member #2, who no longer resides in the home. Lifesharing Specialist was retrained on Regulation 6500.110 (a) on 8/27/2020, attachment #40. Fire Safety training and an updated plan will occur annually, or if Individual #1¿s need change. Training will include all information listed in Regulation 6500.110(a). |
09/02/2020
| Implemented |
| 6500.110(b) | The fire safety training plan for the home does not include evacuation procedures, the use of fire extinguishers and smoke detectors, and notification of the local fire department. | The training plan shall include training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the home, smoking safety procedures if any individuals or family members smoke in the home, the use of fire extinguishers and smoke detectors and notification of the local fire department as soon as possible after a fire is discovered. | A home visit was completed on 8/27/2020 that included updated fire safety training, for Individual #1 & Staff #1, attachment #21. The fire safety training included evacuation procedures, the use of fire extinguishers and smoke detectors, and notification of the local fire department. Staff #1 and Lifesharing Specialist were retrained on Regulation 6500.110 (b) on 8/27/2020, attachment #22. Fire Safety training will occur annually, or if Individual #1¿s need change. Training will include all information listed in Regulation 6500.110(b). |
09/02/2020
| Implemented |
| 6500.121(c)(1) | Individual #1's current, 11/25/2019 physical examination record does not include that a review of the individual's previous medical history was completed. | The physical examination shall include: (1.) A review of previous medical history. | A Clinton County Community Connections physical form along with a lifetime medical history, attachment #29, was sent to Individual #1¿s doctor on 8/21/2020 for review. The lifetime medical history included a review of previous medical history. Lifesharing Specialist was retrained on Regulation 6500.121 (c)(1) on 8/27/2020, attachment #30. When a physical is due for Individual #1, a lifetime medical history will be attached to the physical examination form, to ensure the previous medical history is reviewed yearly. |
09/01/2020
| Implemented |
| 6500.121(c)(2) | Individual #1's current, 11/25/2019 physical examination record does not indicate if a general physical examination was completed on the individual by their physician at the time the physical examination record was completed. | The Physical examination shall include: (2.) A general physical examination. | A Clinton County Community Connections physical form, attachment #31, was sent to Individual #1¿s doctor on 8/21/2020 for review. The physical form included a general physical exam. The physical was completed and returned to Clinton County Community Connections on 9/01/2020. Attachment #32 is the completed physical form. Lifesharing Specialist was retrained on Regulation 6500.121 (c)(2) on 8/27/2020, attachment #38. When a physical is due for Individual #1, Clinton County Community Connections will provide Staff #1 and Individual #1 with the approved physical form, to ensure a general physical exam is completed. |
09/02/2020
| Implemented |
| 6500.121(c)(6) | Individual #1's current, 11/25/2019 physical examination record does not include Tuberculin skin testing by Mantoux method with negative results or an initial chest x-ray with results noted. | Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | A Clinton County Community Connections physical form, attachment #31, was sent to Individual #1¿s doctor on 8/21/2020 for review. The physical form included information on the last Mantoux Screening. The physical was completed and returned to Clinton County Community Connections on 9/01/2020. Attachment #32 is the completed physical form; page 1 lists the date of Individual #1¿s last Mantoux Screening. Lifesharing Specialist was retrained on Regulation 6500.121 (c)(6) on 8/27/2020, attachment #36. When a Mantoux is due for Individual #1, Clinton County Community Connections will provide Staff #1 and Individual #1 with the approved Mantoux form, attachment #37, to ensure a Mantoux Screening is completed every 2 years. |
09/02/2020
| Implemented |
| 6500.121(c)(7) | Individual #1's current, 11/25/2019 physical examination record does not include a gynecological examination including a breast examination and PAP smear or documentation from a licensed physician recommending no or less frequent gynecological examinations. | The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | A Clinton County Community Connections physical form, attachment #31, was sent to Individual #1¿s doctor on 8/21/2020 for review. The physical form included information on the last gynecological exam/whether one is needed or not. The physical was completed and returned to Clinton County Community Connections on 9/01/2020. Attachment #32 is the completed physical form; page 1 lists the gynecological information. Lifesharing Specialist was retrained on Regulation 6500.121 (c)(7) on 8/27/2020, attachment #35. When a physical is due for Individual #1, Clinton County Community Connections will provide Staff #1 and Individual #1 with the approved physical form, to ensure gynecological information is reviewed at the annual physical. |
09/02/2020
| Implemented |
| 6500.121(c)(8) | Individual #1 is over 60 years old and her current, 11/25/2019 physical examination record does not include a mammogram or documentation from a licensed physician recommending no or less frequent mammograms. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | A Clinton County Community Connections physical form, attachment #31, was sent to Individual #1¿s doctor on 8/21/2020 for review. The physical form included the date of her last mammogram. The physical was completed and returned to Clinton County Community Connections on 9/01/2020. Attachment #32 is the completed physical form; page 1 lists the date of her last mammogram. Lifesharing Specialist was retrained on Regulation 6500.121 (c)(8) on 8/27/2020, attachment #34. When a physical is due for Individual #1, Clinton County Community Connections will provide Staff #1 and Individual #1 with the approved physical form, to ensure mammogram information is reviewed at the annual physical. |
09/02/2020
| Implemented |
| 6500.121(c)(14) | Individual #1's current, 11/25/2019 physical examination record does not include any medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A Clinton County Community Connections physical form, attachment #31, was sent to Individual #1¿s doctor on 8/21/2020 for review. The physical form included medical information pertinent to diagnosis and treatment in case of an emergency. The physical was completed and returned to Clinton County Community Connections on 9/01/2020. Attachment #32 is the completed physical form; page 2 states the medical information pertinent to diagnosis and treatment in case of an emergency. Lifesharing Specialist was retrained on Regulation 6500.121 (c)(14) on 8/27/2020, attachment #33. When a physical is due for Individual #1, Clinton County Community Connections will provide Staff #1 and Individual #1 with the approved physical form, to ensure medical information pertinent to diagnosis and treatment in case of an emergency is reviewed at the annual physical. |
09/02/2020
| Not Implemented |
| 6500.125(a) | Family member #2 lived at the home with Individual #1, from Individual #1's 3/20/2020 admission to the home until 7/20/2020. There is no evidence that Family member #2 received a physical examination within 12 months prior to Individual #1 moving into the home. Staff person #3 reported during the 7/29/2020 inspection that a physical examination was never requested or obtained for Family member #2 from the agency. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | Staff Person #3 and Lifesharing Specialist were retrained on Regulation 6500.125(a) on 8/27/2020, attachment #25. When opening a new home, or a new person moves into the Lifesharing home, Clinton County Community Connections will provide CCCC¿s approved physical examination record, attachment #24, to all members of the household prior to start date. The date of this physical will be prior to move in date. Once the physical is obtained, move in will be approved. The physical date and form will be kept in the Lifesharing home¿s record. |
08/31/2020
| Implemented |
| 6500.125(c)(2) | Family member #2 lived at the home with Individual #1, from Individual #1's 3/20/2020 admission to the home until 7/20/2020. There is no evidence that Family member #2 received a Tuberculin skin test by Mantoux method with negative results or an initial chest x-ray with results noted, within 12 months prior to Individual #1 moving into the home. Staff person #3 reported during the 7/29/2020 inspection that a physical examination including Tuberculin skin testing results, was never requested or obtained for Family member #2 from the agency. | The physical examination shall include: (2) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a 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 licensed practical nurse instead of a licensed physician. | Staff Person #3 and Lifesharing Specialist were retrained on Regulation 6500.125(c)(2) on 8/27/2020, attachment #26. When opening a new home, or a new person moves into the Lifesharing home, Clinton County Community Connections will provide CCCC¿s approved Mantoux Screening Form, attachment #27, to all members of the household prior to move in. This form states the results of the screening. The date of this Mantoux test will be prior to move in date. Once the Mantoux screening form is obtained, move in will be approved. The Mantoux Test date and form will be kept in the Lifesharing home¿s record. |
08/31/2020
| Implemented |
| 6500.125(c)(3) | Family member #2 lived at the home with Individual #1, from Individual #1's 3/20/2020 admission to the home until 7/20/2020. There is no evidence that Family member #2 received a physical examination to include a signed statement from their physician indicating they are free of communicable diseases or specific precautions to be taken if the person has a communicable disease, within 12 months prior to Individual #1 moving into the home. Staff person #3 reported during the 7/29/2020 inspection that a physical examination including a signed statement from the family member's physician that they are free off communicable diseases, was never requested or obtained for Family member #2 from the agency. | The physical examination shall include: (3) A signed statement that the person is free of communicable diseases or specific precautions to be taken if the person has a communicable disease. | Staff Person #3 and Lifesharing Specialist were retrained on Regulation 6500.125(c)(3) on 8/27/2020, attachment #23. When opening a new home, or a new person moves into the Lifesharing home, Clinton County Community Connections will provide CCCC¿s approved physical examination record, attachment #24, to the new member of the household prior to move in. This form states that the person is free from communicable diseases. The date of this physical will be prior to move in date. Once the physical is obtained, move in will be approved. The physical date and form will be kept in the Lifesharing home¿s record. |
08/31/2020
| Implemented |
| 6500.34(a) | The Department issued updated, regulatory Individuals' rights effective 2/3/2020, stating that individuals have additional rights to be informed of. At the time of the 7/29/2020 annual inspection, Individual #1 was never informed of their rights as described in 6500.32(e), (f), (p), (q), (r), (s), (u), and (v). | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | Clinton County Community Connections updated the Request and Consent Release Package on 8/24/2020 to include 6500.32 (e), (f), (p), (q), (r), (s), (u), and (v), attachment #13. This Release Package was reviewed with Individual #1 on 8/27/2020, attachment #14. Lifesharing Specialist was retrained on Regulation 6500.34(a) on 8/27/2020, attachment #15. The Release package will be reviewed with Individual #1 annually and/or when changes are made to the package. |
08/27/2020
| Implemented |
| 6500.45(a) | Individual #1 moved in with Family member #1 on 3/20/2020. At the time of the 7/29/2020 annual inspection, there is no evidence that she received training by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques. | The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter. | Staff #1 and Lifesharing Specialist were retrained on Regulation 6500.45(a) on 8/27/2020, attachment #9. Staff #1 received Basic First Aid Training on 8/31/2020, attachment #10. When Staff #1¿s CPR Certification is due for renewal, Staff #1 will be trained via Red Cross training, which includes both CPR & Basic First Aid. |
08/31/2020
| Implemented |
| 6500.47(b)(2) | At the time of the 7/29/2020 annual inspection, there is no evidence that Individual #1's primary caregiver, Family member #1, received training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with OAPSA. | The orientation must encompass the following areas: the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the Child Protective Services Law (23 Pa.C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff #1 was trained on prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with OAPSA on 8/27/2020, attachment #6. Staff #1 and Lifesharing Specialist were retrained on Regulation 6500.47 (b) (2) on 8/27/2020, attachment #7. Residential Director has updated the Provider Orientation Training to include training on Older Adult Protective Services, attachment #8. |
08/31/2020
| Implemented |
| 6500.47(b)(5) | At the time of the 7/29/2020 annual inspection, there is no evidence that Individual #1's primary caregiver, Family member #1, received any training in Individual #1's specific individual plans, behavior support plan, health and safety needs, etc. Individual #1 moved in with Family member #1 on 3/20/2020. | The orientation must encompass the following areas: Job-related knowledge and skills. | Orientation Training records were retrieved, and training on Individual #1¿s diagnoses were completed on 3/20/2020, attachment #1. Individual #1¿s file, which included the ISP, health & safety needs, plans of support, medications, etc. were reviewed with Staff #1 on 3/05/2020, attachment #2. A home visit was completed on 8/27/2020 where Individual #1¿s Individual Support Plan, health & safety needs, medications, etc. were reviewed with Staff #1, attachment #3. Staff #1 and Lifesharing Specialist were retrained on Regulation 6500.47 (b) (5) on 8/27/2020, attachment #4. Residential Director has updated the Provider Orientation Training to include specific training on Individual¿s Records (ISP, Plans of Support, etc.), attachment #5. |
09/02/2020
| Implemented |
| 6500.48(a) | Individual #1's primary caregiver, Family member #1, has been employed with the agency since 9/5/18. At the time of the 7/29/2020 annual inspection, there is no evidence that she received 24 hours of training within the first year of her date of hire. | The primary caregiver and the life sharing specialist shall complete 24 hours of training related to job skills and knowledge each year. | Staff #1 and Lifesharing Specialist were retrained on Regulation 6500.48(a) on 8/27/2020, attachment #20. Staff #1 will receive 24 hours of training annually, for as long as Staff #1 is a Provider for Clinton County Community Connections, regardless if an individual is living in the home. The Training Designee will keep track of all Lifesharing Provider¿s training records. Quarterly reviews will be completed to ensure training hours are being completed throughout the training year. |
08/31/2020
| Implemented |
| 6500.139(a) | The Department issued updated, 55 Pa. Code § 6500 regulatory regulations on 2/3/2020, effective immediately, stating a person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration). Family member #1 administers medications to Individual #1. Family member #1 never received training in the Department's medication administration course.
· A national pandemic was issued on 3/16/2020 which triggered the release of temporary modifications to 55 Pa. Code § 6500 regulations during the pandemic. According to the Office of Developmental Programs (ODP) announcement 20-032, in leu of completing the Department's medication administration course, persons administering medications could complete all the following in place of the entire course: complete a modified medication administration training course, receive training from the provider on the use of the provider's medication record for documenting the administration of medication, have a medication trainer observe the family member administering medications four times, and have the medication trainer observe the family member applying proper handwashing and gloving techniques one time. All modified medication administration requirements, except for the modified medication training course, were never completed for Family member #1. Staff person #3 confirmed on 7/29/2020, that Family member #1 only received training on a modified medication administration training course on 2/20/2020 as part of the agencies plan of correction from their 5/14/2019 annual inspection, and not due to updated regulatory requirements or the Department's release of temporary modifications during a Pandemic. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration). | Staff #1 took the Modified Medication Training Course on 2/20/2020, attachment #16. Staff #1 was scheduled to receive Clinton County Community Connections Agency Medication Training on 3/17/2020. However, due to the COVID-19 pandemic, Clinton County Community Connections was not able to provide Staff #1 with the agency Medication Training. Clinton County Community Connections Medication Trainer completed 1 observation, attachment #17, and proper handwashing and gloving techniques, attachment #18, on 9/01/2020. CCCC Medication Trainer will complete 1 more observation by 9/18/2020. Staff #1 will receive the CCCC agency Medication Administration Course by a Certified Medication Trainer when COVID-19 pandemic is over. Staff #1 will continue to be observed passing medications on a quarterly basis by a CCCC Certified Medication Trainer. |
09/02/2020
| Implemented |
| Article X.1007 | Clinton County Community Connections 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). Family member #2 was 18 years of age as of 8/28/2019, resided in the home when Individual #1 moved in on 3/20/2020, and thus, required an application for a Pennsylvania criminal history record check submitted to the State Police prior to an individual living or receiving respite care in the home. Staff person #3 reported during the 7/29/2020 inspection that a Pennsylvania criminal history record check was never requested or obtained for Family member #2 from the agency. | 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. | Staff Person #3 and Lifesharing Specialist were retrained on Regulation 6500.Article X.1007 on 8/27/2020, attachment #28. When opening a new home, or a new person 18 years of age or older moves into the Lifesharing home, Clinton County Community Connections will run a Pennsylvania Background Check prior to move in. When the background check has come back, Clinton County Community Connections will review the background check and make the approval for the person to move in. The background check will be kept in the Lifesharing home¿s record. |
08/31/2020
| Implemented |