| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessments were completed in January, February, and March of 2022. The time frame allowed by this regulation is April through July (based off of a license expiration in October) or August through November (with the last inspection having been completed in May). | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agencys certificate of compliance, to measure and record compliance with this chapter. | MERAKEY RECOGINZES WE CAN NOT CORRECT THIS VIOLATION. MOVING FORWARD SELF-ASSESSMENT TOOLS WILL BE COMPLETED WITHIN 3 TO 6 MONTHS PRIOR TO THE EXPIRATION DATE OF THE AGENCYS CERTIFICATE OF COMPLIANCE, TO MEASURE AND RECORD COMPLIANCE WITH THIS CHAPTER. 2023 SELF-ASSESSMENTS WILL BE COMPLETED BETWEEN THE MONTHS OF APRIL ULY. |
04/21/2023
| Implemented |
| 6400.15(c) | F0r the following homes, there were violations identified (see violation numbers below), however, there were no summary of corrections made.
1421 Jefferson Avenue Portage home-
141a-comment written but no summary of corrections made notated.
167a1,167a2, & 167a4- violations identified but there were no comments written or summary of corrections made.
642 Highland ave. Revloc home-
181a-f- All the assessment regulations were cited and comments read "duplicate from previous year" but there was no summary of corrections made notated.
185.3- A description was given but no summary of corrections made were notated.
220 Campbell Dr. Duncansville home-
167b, & 167c- these were identified as violations but was no summary of corrections made notated.
167a1, 167a2, 167a3- violations were identified with comments but there was no summary of corrections notated.
751 Ashcroft Ave. Cresson home --
181a-f, 184.4, 185.c, and 195.c -- There were no summary of corrections made.
206 Alba Drive Lilly
52a1- Violation identified but no summary of corrections made was notated.
167a2- comment provided but there was no summary of corrections made notated. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| MERAKEY REVIEWED THE SELF-ASSESSMENTS PROVIDED AT THE TIME OF LICENSING AND DOCUMENTED THE SUMMARY OF CORRECTIONS (SAMPLE ATTACHED #3 |
04/21/2023
| Implemented |
| 6400.110(e) | At the time of the inspection, the smoke detectors were not interconnected, and the home had three floors; it had a basement, 1st floor, and 2nd floor. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | ON THE DAY THIS VIOLATION WAS RECOGNIZED THE TEAM NOTIFIED MAINTENANCE OF THE NEED TO INTERCONNECT THE SMOKE ALARMS THROUGHOUT ALL THREE FLOORS OF CAMBELL DRIVE (ATTACHEMENT #4). ON APRIL 13, 2023 THE SMOKE ALARMS WERE UPDATE TO MEET REGULATION 110(E). |
04/13/2023
| Implemented |
| 6400.166(d) | For individual #1, the script for hydrocortisone 1% cream stated, "apply to affected area topically twice daily as needed for 30 days" but the MAR instructions state, "apply to affected area rectally twice daily for hemorrhoids" and is listed as a PRN.
it is unclear if the medication is supposed to be given as needed for 30 days or twice daily every day without a time limit.
These directions should be clarified with the prescriber, and the label and MARS updated to match so that the directions are clear on how this medication is to be given/utilized. | The directions of the prescriber shall be followed. | THE PRN MEDICATION HYDROCORTISONE 1% CREAM WAS DISCONTINUED APRIL 13, 2023 AS THE 30 DAY ORDER PRESCRIBED BY INDIVIDUAL #1¿S DOCTOR HAS EXPIRED (MAR ATTACHMENT #7). THE PCP APPROVED OVER THE COUNTER MEDICATION LIST (ATTACHMENT #8) PRESCRIBES THIS MEDICATION AS NEEDED MOVING FORWARD. |
04/20/2023
| Implemented |