Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.101 | The door to the attic had a latch lock with a combo preventing immediate exit from room if lock was engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The combination lock was removed during inspection by the Executive Director which provides for immediate exit from attic. |
07/19/2022
| Implemented |
6400.52(c)(2) | Documentation was not provided notating the completion of training of abuse prevention detection and reporting for the 2021 training year for staff 2. | The annual training hours specified in subsections (a) and (b) 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. | The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available.
Staff 2 is currently on leave and will receive the required 2022 training upon her return. |
07/23/2022
| Implemented |
6400.52(c)(3) | Documentation was not provided notating the completion of training of individual rights for the 2021 training year for staff 2. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available.
Staff 2 is currently on leave and will receive the required 2022 training upon her return. |
07/23/2022
| Implemented |
6400.52(c)(4) | Documentation was not provided notating the completion of training of recognizing and reporting incidents for the 2021 training year for staff 2. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available.
Staff 2 is currently on leave and will receive the required 2022 training upon her return. |
07/23/2022
| Implemented |
6400.52(c)(5) | Documentation was not provided notating the completion of behavioral supports for the 2021 training year for staff 2. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available.
Staff 2 is currently on leave and will receive the required 2022 training upon her return. |
07/23/2022
| Implemented |
6400.169(d) | Prior to June 2022, there is no record of medication administration training for staff 2, The medication trainings provided show that Amelia was medication trained on 6/21/22 but not prior to the aforementioned date. Staff administered medication during the undocumented period. | 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 agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. |
07/01/2022
| Implemented |