| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(e) | A dental appointment on 8/11/22 indicates that individual #1 was referred to an oral pathologist for treatment. No indication that was completed. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Individual#1 oral pathologist has been scheduled for Oral Pathology appointment on 3/20/23 at 11am with University of Penn School of Dental Medicine, 240 S. 40th St. at 10:30am, which is the earliest for this appointment. |
01/23/2023
| Implemented |
| 6400.46(a) | Staff #1's 4/28/22 Fire Safety Training did not include site specific fire safety areas as Kencidd does this separately in the form of SSO (site specific orientation). | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff#1 received a Site-Specific Orientation (SSO) in accordance with 6400.46a during their next scheduled workday on 12.24.2022. see violation 1 attachment #1. |
12/24/2022
| Implemented |
| 6400.169(a) | Staff #1's Medication training practicum states initial is undated, lists only two, instead of the required four practicums and does not indicate if she passed or failed. | 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 § 6400.162 (relating to medication administration). | The practicum observer was retrained to assure that all medication training practicum observations are completed according to regulation on 12/20/2022. See attachment#3
Staff #1 received additional medication practicum observation on 1/27/2023. See attachment#3a. |
12/20/2022
| Implemented |