Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6500.62(d) | Finish Jet Dry and Windex cleaning supplies, which indicated on product labels to contact poison control if ingested, were found stored with potatoes under the kitchen sink. Tide laundry detergent, Clorox bleach and Spectracide Wasp and Hornet Killer pesticide spray, which indicated to contact poison control if ingested, were found stored with cereal and pasta in the laundry room area of the home. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | 1. The chemicals were removed on 4/12/2016. A cabinet was installed to store all poisonous substances on 5/24/2016. See attachment #5.
2. All other sites were reviewed during the annual 6500 inspection on 4/11/16 and 4/12/2016.
3. In order to prevent reoccurrence, the Program Director retrained the Program Specialist on 55 PA Code Chapter 6500.62(d) on 8/18/2016. See attachment #2. The Program Specialist will remove any poisonous materials that are not stored separate from food, food preparation surfaces and dining surfaces whenever physical site non-compliance is recognized. The Program Coordinator/Property manager will conduct site inspections for each licensed program once a quarter and document the results using the Licensing Inspection Instrument Score Sheet section Physical Site. All areas of non-compliance will result in a plan of correction and retraining. |
10/01/2016
| Implemented |
6500.103 | There was no documentation that the gas or electric furnace filter was changed. | Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept. | 1. The last heater inspection was completed 5/9/2016 and 9/4/2015. See attachment #4. This was not present during the inspection.
2. All other sites were reviewed during the inspection on 4/11/16 and 4/12/2016.
3. In order to prevent reoccurrence, the Program Director, retrained the Property Manager and Program Specialist/Coordinator on implementation of 55 PA Code Chapter 6500.103 on 8/18/2016. See attachment #2. A spreadsheet will be used by the Property Manager to track heater inspection dates to ensure compliance. See attachment #6. The Program Director will monitor compliance during quarterly 1:1 meetings with the Property Manager. |
10/01/2016
| Implemented |
6500.121(c)(14) | Individual # 1's physical examination dated 10/26/2015 did not document 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. | 1. The Primary Physician completed the Annual Physical section titled "information pertinent to diagnosis and treatment in case of an emergency" and was received by the agency on 5/13/2016 with the required section completed. See attachment #3
2. The Program Nurse will review all individuals' current physical exam forms by 10/1/2016. All non-compliant areas will be sent to the Primary Care Physician(s) by the Program Nurse via fax recommending the areas are addressed.
3. In order to prevent reoccurrence, the Program Director, retrained the Program Nurse and Program Specialist on implementation of 55 PA Code Chapter 6500.121(c)(15) on 8/18/2016. See attachment #2. The Program Specialist will conduct a quarterly audit using the Licensing Inspection Instrument Score Sheet section Individual Health to track future compliance. The Program Specialist Supervisor will track and monitor the audit results. |
10/01/2016
| Implemented |
6500.121(c)(15) | Individual #1's physical examination dated 10/26/2015 did not document special instructions for the individual's diet. | The physical examination shall include: Special instructions for the individual's diet. | 1. The Primary Physician completed the Annual Physical section titled "recommended diet and special instructions" and was received by the agency on 5/13/2016 with the required section completed. See attachment #3
2. The Program Nurse will review all individuals' current physical exam forms by 10/1/2016. All non-compliant areas will be sent to the Primary Care Physician(s) by the Program Nurse via fax recommending the areas are addressed.
3. In order to prevent reoccurrence, the Program Director, retrained the Program Nurse and Program Specialist on implementation of 55 PA Code Chapter 6500.121(c)(15) on 8/18/2016. See attachment #2. The Program Specialist will conduct a quarterly audit using the Licensing Inspection Instrument Score Sheet section Individual Health to track future compliance. The Program Specialist Supervisor will track and monitor the audit results. |
10/01/2016
| Implemented |
6500.156(b) | Individual #1's three month ISP review documentation covering the period of 08/20/2015-11/20/2015 was not signed by the family living specialist. | The family living specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | 1. Individual #1's ISP review documentation covering the period of 08/20/2015-11/20/2015 was signed on 12/16/2015. See attachment #1.
2. The program specialist will review all individuals' latest quarterly review by 10/1/2016 and document compliance on 55 PA Code Chapter 6500.156(b). If noncompliance is noted the Program Specialist will be retrained on 55 PA Code Chapter 6500.156(b) by the Program Specialist Supervisor.
3. In order to prevent reoccurrence, the Program Director retrained the Program Specialist on implementation of 55 PA Code Chapter 6500.156(b) on 8/18/2016. See attachment #2. The Program Specialist will conduct a quarterly audit using the Licensing Inspection Instrument Score Sheet section Plan Review and Plan Revision to track future compliance. The Program Specialist Supervisor will track and monitor the audit results. |
10/01/2016
| Implemented |