Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The desk in the vacant upper level bedroom used for art was damaged. The two left drawers were broken. | Floors, walls, ceilings and other surfaces shall be in good repair. | The desk has been replaced. All homes have been inspected by maintenance personnel to insure that equipment and furnishings are in good repair. |
07/10/2022
| Implemented |
6400.82(e) | The main level shower did not have a non slip mat or surface. | Bathtubs and showers shall have a nonslip surface or mat. | The mat that was previously in the shower was discarded and not replaced. A new mat was purchased and is now in place in the shower. All other homes were inspected by maintenance personnel and found to have non-skid surfaces in the showers. |
07/15/2022
| 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 1. | 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. |
07/19/2022
| Implemented |
6400.52(c)(3) | Documentation was not provided notating the completion of training of individual rights for the 2021 training year for staff 1. | 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. |
07/19/2022
| 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 1. | 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. |
07/19/2022
| Implemented |
6400.52(c)(5) | Documentation was not provided notating the completion of training of behavioral supports for the 2021 training year for staff 1. | 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. |
07/19/2022
| Implemented |
6400.169(d) | There is no record of medication administration training for staff 1 prior to June 27, 2022. Staff administered medication the month of June and prior months. The medication trainings provided show that staff 1 was currently trained on 6/27/22. | 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 |