Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(c) | The fire drills held during months of Sept, Oct, Nov, Dec 2021 all state "2 mins" for the evacuation time. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drill form is being updated to capture the missing information and will begin to be used on July 1, 2022. |
07/01/2022
| Implemented |
6400.141(c)(6) | There is no current TB test on file for individual #4. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | An appointment was made for the individual for a PPD to be placed on 06/07/2022. |
06/07/2022
| Implemented |
6400.141(c)(7) | There is no current gynecological exam on file for individual #4. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Gynecological exam is scheduled for the individual. This was scheduled at the time of the audit and the information provided to the auditor. The appointment is 06/17/2022. |
06/17/2022
| Implemented |
6400.142(d) | The Dental exam dated 2/22/22 for individual #4 did not indicate that a cleaning was performed at the appointment. | The dental examination shall include teeth cleaning or checking gums and dentures. | Dental exam is scheduled for the individual and the information was provided to the auditor during the inspection. The appointment is 06/04/2022 to remove her braces and the cleaning appointment is 06/06/2022. |
07/01/2022
| Implemented |
6400.166a | Regarding Individual #4's medication review: Medication acetaminophen was found in the individual's medication container as a prescribed PRN, but not listed on the MAR. | Notification of an adverse reaction to a medication may be made to the prescribing certified registered nurse practitioner (CRNP) when the medication was prescribed by a CRNP as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners).
| The MAR was corrected and the pharmacy contacted to ensure their information is accurate. |
07/01/2022
| Implemented |
6400.181(a) | The assessment for individual #4 dated 1/16/22 was not completed up to regulatory standards.
-The regulations state that the assessment cannot be vague or non-specific. It also states an assessment is to be meaningful accurate and useful. As such the provided assessment did not provide thorough documentation of:
- Functional strengths
- Likes and dislikes of the individual
- Ability to safely avoid poisons
- Ability to evacuate in the event of a fire
- A lifetime medical history
Additionally there is no documentation showing that the assessment was sent to the team 30 days before the ISP meeting. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The assessment was updated. An annual ISP has not been completed as her admission was in December 2021. |
07/01/2022
| Implemented |
6400.163(d) | Regarding Individual #4's medication review: The medication Loratadine 10mg tablet is listed on the MAR as a PRN, but was not found with the individual's medication container | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The PRN medication was filled and is now in the medication container. |
06/01/2022
| Implemented |
6400.165(g) | There is no documentation that individual #4received psychiatric medication reviews every 90 days. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The individual is prescribed her medications from her PCP. She does see her PCP regularly for refills. The appropriate paperwork will be sent to the PCP so they are able to complete the requirements for psychiatric checks until a psychiatrist is found. |
07/01/2022
| Implemented |
6400.166(a)(4) | Regarding Individual #4's medication review: Medication Deso/ethinyl .01mg tablet was so named on the blister pack; the MAR identifies the medication as Volnea .01mg tablet. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The MAR was corrected and the pharmacy contacted to ensure their information is accurate. |
07/01/2022
| Implemented |
6400.166(b) | Regarding Individual #4's medication review: Medications Guanfacine 1mg tablet and Deso/ethinyl .01mg tablet (both 8AM doses) were not signed off on the MAR; the blister packs indicated that they had been given. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff will be retrained on completing the electronic MAR by 07/01/2022. |
07/01/2022
| Implemented |
6400.213(1)(i) | There was no current dated photograph present in the file of individual #4. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The individual now has a current photo as part of the record. |
05/04/2022
| Implemented |