Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(e) | The trash can in Individual #1's bedroom is over 18 inches and did not have a lid. | Trash receptacles over 18 inches high shall have lids. | This individual has a tendency to throw away the transcan lids on her trashcans. She has also occasionally thrown out lids on other trashcans. The individual has been asked to stop doing this, and explained why a lid is important and a new trashcan has been purchased. Program Staff have asked that this information be added to the individuals ISP.
See attachment K
Physical site inspections is part of the monthly site mountings completed by Program Managers monthly.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
|
12/03/2014
| Implemented |
6400.67(a) | Individual#1's bedroom door has a fist size hole in the right corner and the paint is chipping off of the door in different areas on the inside. | Floors, walls, ceilings and other surfaces shall be in good repair. | The hole in the bedroom door was patched and the door was painted.
See attachment F.
Physical site inspections is part of the monthly site mountings completed by Program Managers monthly.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
|
09/15/2014
| Implemented |
6400.67(b) | The porch on the back of the home is warping over the stairs causing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The back deck was completely removed and replaced with a new deck.
See attachment F.
Physical site inspections is part of the monthly site mountings completed by Program Managers monthly.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
|
10/30/2014
| Implemented |
6400.80(b) | On the back porch by the sliding glass door the house is rotting & the paint is chipping. The ramp going into the garage is chipping & the seal to the door is coming off. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The wood around the sliding glass door was replaced. The ramp going into the garage was repainted and the seal on the door was replaced.
See attachment F
Physical site inspections is part of the monthly site mountings completed by Program Managers monthly.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
|
11/15/2014
| Implemented |
6400.82(f) | In Individual #1's bathroom did not contain any toilet paper or indivdual wipes. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The individual who uses this bathroom keeps her toilet paper in the closet outside of her bathroom. She is independent in the area of ensuring that toilet paper is in the bathroom when she needs this. Staff have been trained to provide more oversight in this area, without taking away the individuals independence.
Physical site inspections is part of the monthly site mountings completed by Program Managers monthly.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
|
08/13/2014
| Implemented |
6400.168(a) | Staff person #1 medication training was completed on 4/1/14. The 2013 medication training had not been completed and this staff person was administering medications. Staff person #2 had not been trained on medication administration and was administering medications. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Annual recertification for Staff person #1 did take and pass the did occur in 2013, however the appropriate documentation to prove this was missing from the file. This individual is currently being monitored as part of the ongoing medication monitoring process (quarterly MAR reviews and 2 annual med passes). There is no way to go back and recreate the paperwork from their annual training, therefore the staff will continue to receive annual monitoring.
Staff person #2 did take and pass the Medication Administration course. The appropriate documentation to prove this was missing from the file. This individual is currently being monitored as part of the ongoing medication monitoring process (quarterly MAR reviews and 2 annual med passes). There is no way to go back and recreate the paperwork from their annual training, therefore the staff will continue to receive annual monitoring.
All Residential Supervisors and Program Managers received additional training regarding this matter/regulation on August 13, 2014
See attachment A
A new process was developed to ensure that copies of medication administration packets are kept once turned into Penn-Mar's training department. This will help to ensure that paperwork is not lost or misfiled. This information is also tracked as part of Penn-Mar's Quality Management plan. Data is kept on this information as part of the Quality Management pla
|
08/13/2014
| Implemented |