| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff 3 who also works at another location was hired on 6/1/21, however the criminal history background check was not requested until 10/31/21. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Plan of Correction: Based on the licensing review of November 8-9, 2021, the newly appointed Director of Human Resources, retrained the HR Operations Manager on 11/12/21 about the importance of assuring that all prospective PATH staff who will have direct contact with individuals have a criminal history record check completed within 5 working days after the date of hire. (If they are not a resident of the Commonwealth, a Federal Bureau of Investigation (FBI) Criminal History Record check will be completed within five working days after their date of hire). |
11/16/2021
| Implemented |
| 6400.67(a) | The top right dresser drawer in bedroom of Individual 3 was unstable and not on the track. The dresser pull knobs were missing on drawer in bedroom of individual 4. | Floors, walls, ceilings and other surfaces shall be in good repair. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of maintaining clean and sanitary conditions at all sites. It is the responsibility of Site Supervisor to assure that site furniture is in good repair on a weekly basis. The residential staff at this site were also given verbal feedback about the importance of complying with 6400 regulations on the day regarding assuring that all furniture remain in good repair (11.08.21). |
11/09/2021
| Implemented |
| 6400.52(c)(2) | ." The training record shows that Staff 2 received this training on 10/13/2020 and 11/03/2021, exceeding 1 year between trainings on this topic, even allowing for the 15-day grace period. The training record does not reflect that these topics were covered through other trainings taken by the staff during the review period. | 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. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the training, as well as the Assistant Directors about the importance of ensuring that annual trainings stay within regulatory guidelines. Additionally, the training department was made aware of the need to be regulatory compliant as well. |
11/10/2021
| Implemented |
| 6400.52(c)(3) | The training record shows that Staff 2 received this training on 10/13/2020 and 11/03/2021, exceeding 1 year between trainings on this topic, even allowing for the 15-day grace period. The training record does not reflect that these topics were covered through other trainings taken by the staff during the review period. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the completion of the training, as well as the Assistant Directors about the importance of ensuring that annual trainings stay within regulatory guidelines. Additionally, the training department was made aware of the need to be regulatory compliant as well. |
11/10/2021
| Implemented |
| 6400.52(c)(4) | The training record shows that Staff 2 received this training on 10/13/2020 and 11/03/2021, exceeding 1 year between trainings on this topic, even allowing for the 15-day grace period. The training record does not reflect that these topics were covered through other trainings taken by the staff during the review period. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the completion of the training, as well as the Assistant Directors about the importance of ensuring that annual trainings stay within regulatory guidelines. Additionally, the training department was made aware of the need to be regulatory compliant as well. |
11/10/2021
| Implemented |
| 6400.163(h) | The following as needed medications prescribed to individual 3 were expired on 7/27/2021 and still present in PRN medication bin: Triple antibiotic ointment, Robafen DM LIQ 10-100/5, Milk of magnesia sus 1200/15, dihenhydramine 50 mg cap, Acetaminophen 500 tab, and Loperamine 2mg cap | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | This citation was resolved immediately on 11/8/21, while licensors were still on site; the Site Supervisor removed the expired med from the medication box. Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of disposing of expired or discontinued medication. It is the responsibility of the Site Supervisor to ensure expired medication is properly removed and disposed of as part of their weekly site visit. The residential staff at this site were also given verbal feedback about the importance of complying with 6400 regulations on the day regarding assuring that all expired medication is disposed of in accordance with Federal and State statutes and regulations (11.08.21). |
11/08/2021
| Implemented |