| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | A bottle of Lysol Disinfectant spray (Poison) was found under the bathroom sink by the kitchen unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Following contact from licensing of the unannounced inspection, a Program Manager who was available to be at the home promptly in the event that I was unable to meet the licensing representative. While there, the Manager engaged in light sanitation of the bathroom kitchen area. This manager does not support this particular home or consumers, and therefore, was not fully aware of the poison risks for the home. She returned the Lysol and Envirx spray that she used to the bathroom closet in error. They have since been restored to appropriate location.
This was an unrecognized risk factor across all of our homes with focus being on staff training in individual ISP and identified risks. However, there are times when staff who are not familiar with these risks may be in a home much like the morning of the unannounced inspection. Albeit poor timing, we believe this can be mitigated without drawing attention to any specific consumer or risk assessment for anyone who may be visiting or carrying out a function in a home. |
09/16/2022
| Implemented |
| 6400.62(c) | A spray bottle with blue liquid was found under the bathroom sink by the kitchen. Poisonous materials shall be kept in their original labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | A disinfectant cleaner meeting EPA requirements was purchased by IFC through the PA DOC. The supplied bottles used for spraying had poorly affixed labels that were prone to detachment. Most homes have ceased using this product due to readily available Lysol products at this time. Notice to all homes to assess and remove remaining products by 9/19/22 has been distributed. |
09/19/2022
| Implemented |
| 6400.67(a) | Individual # 2's dresser handle on the bottom right of his dresser was broken. | Floors, walls, ceilings and other surfaces shall be in good repair. | This regulatory area is already identified on the quarterly site assessment. It was due to be completed in the month of July which was subsequent to the unannounced inspection. This tool was developed as a corrective action for our full licensing just recently. July was to be the first full implementation of the tool.
Because we had not received the official POC and the dresser was still functionally accessible, I allowed the supervisor assessment to proceed without notification of the prior licensing finding to him. This was intended to measure efficacy of review tool. The tool was submitted on 7/31/22. The notations included their findings of the dresser needing a handle. This was subsequently remediated. |
09/16/2022
| Implemented |
| 6400.71 | Emergency Telephone numbers were not on or near the telephone in Individual # 1's apartment. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The phone that was identified as having no emergency numbers was for a disconnected line that had been added to the home for the benefit of a single consumer and used in their private space. Following receipt of cell phone and discontinued use of the second land line, the phone service was terminated to manage costs. However, we did not remove the physical phone from their private space. This was not property of the individual and should have been removed to reduce confusion and maintain compliance. The phone has been removed along with all other property due to relocation to new CLA. |
09/16/2022
| Implemented |
| 6400.141(c)(4) | Individual # 1's physical dated 01/17/22 does not indicate that he received a hearing or vision screening. The document states "other". | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | `Other has been removed as a selection for provider to complete. This has been intended to capture recommendation for specialist evaluation when the PCP did not complete the assessment as a part of routine evaluation. Justin has been scheduled for these specialist appointments though there have been ongoing refusals. This is being addressed in subsequent POC item to restore ongoing compliance. |
09/16/2022
| Implemented |
| 6400.143(a) | Individual # 1 refused dental examinations during 2021. There is no desensitization plan in place. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A desensitization plan has been updated for Justin. Prior plan only addresses COVID vaccine refusals. The updated plan is comprehensive and covers all medical assessment areas for which there have been refusals or barriers to completing. This will include pre-appointment encounters with IFC medical staff or BSC as appropriate. There will also be subsequent documentation provided by Support Staff with respect to interventions used and outcomes. This will be completed as an add-on to our current electronic medical consult reporting system. Technical guidance from licensing representative on how to appropriately collect this data is what is being amended in our reporting system. |
09/30/2022
| Implemented |