| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff person #1 hired 6/16/12 did not complete a FBI criminal history check. | (b) If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Staff person has not resided outside the state of Pennsylvania in the past two years as verified by addresses listing residence from 2008 to the present. |
01/30/2014
| Implemented |
| 6400.46(g) | Staff persons #1, #2, #3 did not receive fire safety training by a fire safe expert for the training year 1/1/12 to 12/31/12.
Unannounced Inspection- 10/8/13: Staff persons # 4, #5, #6 did not receive fire safety training by a fire safety expert for the training year 1/1/12-12/31/12. | (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f).
| New Fire training was conducted by the Fire Marshall. This will include all staff and individusls. |
11/30/2014
| Implemented |
| 6400.68(c) | Well water testing was not completed 6/13. | (c) A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.
| Water well testing was completed. We will follow up with documentation in December 15 2013. |
12/14/2013
| Implemented |
| 6400.112(d) | Fire drill exceeded 2 minutes 30 seconds for a fire drill held 9/14/12 for 2 minutes and 35 seconds. | (d) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.
| We are working with the fire Marshall to look into time extention. Information to follow. |
12/15/2013
| Implemented |
| 6400.113(a) | The fire safety training held on 7/1/13 for individual #1 and individual #2 was not completed by a fire safe expert.
Unannounced Inspection- 10/8/13 The fire safety training held on 7/1/13 for individual #3 and individual #4 was not completed by a fire safe expert.
| (a) An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home.
| New Fire training was conducted by the Fire Marshall. This will include all staff and individuals. |
12/13/2013
| Implemented |
| 6400.151(a) | Staff person #3 did not complete a chest x-ray for positive PPD testing with physical examination dated 10/26/11. | (a) 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.
| Staff person #3 ccompleted PPD requested and completed examination 8/29/13. Dcoumentation # 151(a) |
08/29/2013
| Implemented |
| 6400.164(a) | Unannounced Inspection- 10/8/13 : Staff person #3, administers medications and the October, 2013 medication record did not include a full signature. | (a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.
| The medical record has been corrected to indicate the correction signature required. 8/29/13 Doc #164(a) Administrator will monitor nurse to ensure work is do properly. |
08/29/2013
| Implemented |
| 6400.164(b) | Alprazolam 0.56 mg (Xaxax) one tablet three times a day at 8AM, 5PM and 8PM was not initialed as administered on 8/5/13 at 5PM and 8PM for individual #2.
Unannounced Inspection- 10/8/13 : Individual #3 medication log for the following was not initiled as administered for: Simvastatin 40 mg. at 9PM on 9/2/13 and 9/30/13, Vitamin D on 9/18/13-9/20/13, 9/24/13-9/30/13 and calcium 9/27/13 and 9/30/13. | (b) The information specified in subsection (a) shall be logged immediately after each individual's dose of medication.
| Administrator will work with Nurse to ensure administrative work cooincides with medication deliver. Employee will be managed/monitored. |
10/12/2013
| Implemented |
| 6400.167(b) | Alendronate Sodium 70 mg one tablet every Friday at 6:30 PM was initialed as given on 8/3-5/13, Levothyroxine 88 mcg one tablet every other day was initialed as given on 8/1-3/13 and Levothyroxine 75 mcg one tablet every other day was initialed as given on 8/1-2/13 for individual #1.
Calcium 600mg one tablet daily at 9AM was administered twice daily on 8/1-5/13 for individual #2.
| (b) Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.
| Nurse will monitor mediciation to be administered at prescribed time. This action was immediate.Administrator to monitor. |
08/15/2013
| Implemented |
| 6400.181(d)(3) | The plan Lead did not document the ISP on a HCSIS designated form for individual #2. | (3) The ISP, annual updates and revisions shall be documented on the Department-designated form located in the Home and Community Services Information System (HCSIS) and also on the Department's web site.
| ISP are currently completed but will be put into/transferred HCSIS and filled out accordingly.1/30/14 |
01/30/2014
| Implemented |
| 6400.184(b) | Only two team members attended the ISP meeting held 10/26/12 for individual #1. | (b) At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting.
| Going forward the Administrator will monitoring Program Specialist to ensure appropriately measure/attendees are in place. |
08/12/2013
| Implemented |
| 6400.185(b) | The ISP dated 2/26/13 for individual #1 was not implemented as written for outcomes: to take care of a plant, clean off table, scrape off plates and empty scarps into trash can. | (b) The ISP shall be implemented as written.
| Going forward the Administrator will monitoring Program Specialist to ensure appropriate Actions and tasks designated are in completed properly. |
08/12/2013
| Implemented |
| 6400.186(c)(2) | The ISP review held 8/25/12, 11/25/12, 2/25/13 and 5/25/13 for individual #1 did not include a review of medical appointments and summary of ISP outcome to care of a plant, clean off table, scrape off plates and empty scarps into trash can.
The ISP review held 2/1/13, 5/1/13 and 8/1/13 for individual #2 did not include a review of behavioral supports, medical appointments and a summary of outcomes to care for a plant and exercise weekly.
| (2) A review of each section of the ISP specific to the residential home licensed under this chapter.
| Quarterly reviews will address outcomes , medicals , updates and family visits and reported by the program specialist. Documentation#186(c)(2)A-D |
09/12/2013
| Implemented |
| 6400.213(9) | Unannounced Inspection- 10/8/13: A current copy of individual #3 ISP was not included as part of the individual's record. | (9) A copy of the current ISP.
| A copy of current ISP will be kept in individuals binders. Programs Specialist will maintain current ISP. |
10/15/2013
| Implemented |
| 6400.240(b) | The dishwasher hot water temperature did not reach 180 degrees for the rinse cycle. The temperature reached 145 degrees. | (b) A mechanical dishwasher shall use hot water temperatures exceeding 140°F in the wash cycle and 180°F in the final rinse cycle or shall be of a chemical sanitizing type approved by the National Sanitation Foundation.
| Independent contractor to come and monitor dishwasher and track quarterly to ensure it is reaching proper temp. |
12/15/2013
| Implemented |