| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual#1'a funds are not being used for his individual's benefit. Individual #1 had a 6/3/22 Walmart receipt for a Slumber 1 by Zinus Quilted Top 8'' Innerspring Mattress, twin for $129.00. This item should not be purchased using individual's funds as it would be provided by the agency. | Individual funds and property shall be used for the individual's benefit. | A deposit in the amount of $129.00 was made into the account of Individual #1 to rectify the purchase on June 30, 2023. Program Director will be re-trained on the financial auditing process and items covered under the Room & Board Contract and on Regulation 6400.22 (c) by the Program Senior Director by July 30, 2023. |
07/30/2023
| Implemented |
| 6400.64(a) | Clean and sanitary conditions shall be maintained in the home. The ceiling vent located in the upstairs bathroom had a significant layer of dust on it. Individual #2's bathroom ceiling vent located in their bedroom had a significant a significant layer of dust on it. | Clean and sanitary conditions shall be maintained in the home. | Maintenance Request entered for completion of cited concern and ceiling vent will be cleaned by July 30, 2023. Staff at the home. Residence will retrained on the process for submitting work orders and on regulation 6400.64(a) by the Program Director by July 30, 2023. Effective July 1, 2023 a quality assurance audit process has been implemented to increase oversite by requiring multiple levels of leadership to audit, monitor and review all locations to ensure compliance. The Program Director was trained on this new process on June 14, 2023 by the Executive Director. |
07/30/2023
| Implemented |
| 6400.67(a) | Floors, walls, ceilings, and other surfaces shall be in good repair. There were 2 holes located in the wall in Individual #2's bedroom located next to the bathroom door. 1 hole was approximately 1 inch by 2 inches long, and the second hole was approximately 2inches wide by 2 inches long. There was a hole approximately the size of a golf ball in Individual #2's bedroom located on the wall where the window with the air conditioner unit is located. On the ceiling above the stove there were approximately 5 areas where the paint was peeling and chipping, and there were 2 areas where the paint was missing from the ceiling in this same area over the stove. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance Request entered for completion of cited concern. The hole in the wall will be repaired by July 30, 2023. Staff at the home. Residence will retrained on the process for submitting work orders and on regulation 6400.67(a) by the Program Director by July 30, 2023. Effective July 1, 2023 a quality assurance audit process has been implemented to increase oversite by requiring multiple levels of leadership to audit, monitor and review all locations to ensure compliance. The Program Director was trained on this new process on June 14, 2023 by the Executive Director. |
07/30/2023
| Implemented |
| 6400.144 | Health services, such as medical, pharmaceutical, and dental services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 had a dental examination on 11/15/22 and the appointment form noted a return appointment for 5/16/23. There is no documentation or record that a return visit attended by Individual #1. Individual #1 had a vision exam on 4/15/21 and there is no record that one has occurred since. Individual #1 is prescribed Tretinoin 0.25% Cream, apply topically daily at 7am to affected area on the hands and feet. The medication was not available in the home. Individual #1 is prescribed Miracle Foot Cream, apply topically to feet twice a day at 7am and 9pm. Rub in well for 100 seconds. The medication was not available in the home. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| House Staff will be trained by the Program Director by July 30, 2023 on the process and required documentation for Ordering, Receiving & Returning Medication. Program Director will train the house staff on regulation 6400.144 by July 30, 2023. Effective July 1, 2023 a quality assurance audit process has been implemented to increase oversite by requiring multiple levels of leadership to audit, monitor and review all locations to ensure compliance. The Program Director was trained on this new process on June 14, 2023 by the Executive Director. |
07/30/2023
| Implemented |
| 6400.151(a) | Staff #1 had a physical examination on 1/3/20 and their next physical examination occurred on 11/10/22. This exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The HR department was retrained on this regulation regarding employee physical requirements June 22, 2023. Program Coordinators and Directors will receive retraining on July 12, 2023. |
07/12/2023
| Implemented |
| 6400.151(c)(2) | Staff #1 had a Tuberculin skin testing by Mantoux method with negative results on 1/5/20, and their next Tuberculin skin testing by Mantoux method with negative results was completed on 5/19/22. This exceeds the requirement. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if 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 a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The HR department was retrained on this regulation regarding employee physical requirements on June 22, 2023. Program Coordinators and Directors will receive retraining on July 12, 2023. |
07/12/2023
| Implemented |
| 6400.32(r) | An individual has the right to lock the individual's bedroom door. Individual #1 did not have a lock on their bedroom door. | An individual has the right to lock the individual's bedroom door. | Maintenance Request entered for completion of cited concern and keypad doorknobs will be installed by July 30, 2023. Effective July 1, 2023 a quality assurance audit process has been implemented to increase oversite by requiring multiple levels of leadership to audit, monitor and review all locations to ensure compliance. Both the area Director and Coordinator were trained on this new process on June 14, 2023 by the Executive Director. Program Manager and Case Managers will be trained by the Program Director by July 30, 2023 |
07/30/2023
| Implemented |
| 6400.46(b) | Direct service workers shall be trained annually in fire safety training. Staff #1 received annual fire safety on 1/8/21 and then not again until 10/27/22. This exceeds the requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Program Coordinators and Directors will receive retraining on this regulation on July 12, 2023. A procedure has been implemented to remove any employee from the work schedule if they fall out of compliance until they receive the necessary training to be in compliance. |
07/12/2023
| Implemented |
| 6400.46(d) | Direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques, and cardio-pulmonary resuscitation. Staff #1 was trained in first aid and cardio-pulmonary resuscitation on 5/3/22, and there is no record or documentation of them receiving training prior. Staff #1 date of hire is 1/15/18. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Program Coordinators and Directors will receive retraining on this regulation on July 12, 2023. A procedure has been implemented to remove any employee from the work schedule if they fall out of compliance until they receive the necessary training to be in compliance. |
07/12/2023
| Implemented |
| 6400.52(c)(1) | Staff#1 did not receive annual training on the application of person-centered practices, and individual choice. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Program Coordinators and Directors will receive retraining on this regulation on July 12, 2023. A procedure has been implemented to remove any employee from the work schedule if they fall out of compliance until they receive the necessary training to be in compliance.
(Staff is no longer working with the agency -CH 7/26/2023) |
07/12/2023
| Implemented |
| 6400.52(c)(2) | Staff#1 did not receive annual training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | 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. | Program Coordinators and Directors will receive retraining on this regulation on July 12, 2023. A procedure has been implemented to remove any employee from the work schedule if they fall out of compliance until they receive the necessary training to be in compliance.
(Staff member is no longer working with the agency - CH 7/26/23) |
07/12/2023
| Implemented |
| 6400.52(c)(4) | Staff#1 did not receive annual training on recognizing and reporting incident. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Program Coordinators and Directors will receive retraining on this regulation of compliance until they receive the necessary training to be in compliance.
(Staff member is no longer working with the agency - CH 7/26/23) |
07/12/2023
| Implemented |
| 6400.163(h) | Individual #1 prescribed Artificial Tears Drops, instill 2 dops into both eyes 4 times a day at 7am, 12noon, 5pm, and 9pm as needed. The bottle located in the home expired on 6/6/23. The medication remained with the individual's medications and was not disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | House Staff will be trained by the Program Director by June 30, 2023 on the process and required documentation for Ordering, Receiving & Returning Medication. Program Director will train house staff and leadership on regulation 6400.163(h) by June 30, 2023. Effective July 1, 2023 a quality assurance audit process has been implemented to increase oversite by requiring multiple levels of leadership to audit, monitor and review all locations to ensure compliance. Both the area. The Program Director was trained on this new process on June 14, 2023 by the Executive Director. |
07/30/2023
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Amonium Lactate 12% Loti, apply topically to entire body after bathing/showering and also apply to feet and hands at 7am. There were 3 bottles of Amonium Lactate 12% Loti in the home. One bottle had a pharmacy label with the fill date of 7/6/22 and the bottle was approximately ¼ of the way full. The second bottle had a pharmacy label with the fill date of 9/12/22 and bottle was approximately ½ of the way full. The third bottle had fill date of 4/17/23 and the bottle was full. The medication is being documented on the Medication Administration Record (MAR) as being administered as prescribed. | A prescription medication shall be administered as prescribed. | House Staff will be trained by the Program Director by July 30, 2023 on the process and documentation for the administration of medication. Program Director will train house staff and leadership on regulation 6400.165(c) by July 30, 2023. Effective July 1, 2023 a quality assurance audit process has been implemented to increase oversite by requiring multiple levels of leadership to audit, monitor and review all locations to ensure compliance. The Program Director was trained on this new process on June 14, 2023 by the Executive Director. |
07/30/2023
| Implemented |