Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
SIN-00238373
|
Renewal
|
02/27/2024
|
Compliant - Finalized
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.165(g) | Individual #1 is prescribed medications to treat symptoms of psychiatric illness. There are not reviews of these medications at least every three months. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual # 1medications are prescribed by her primary physician and are reviewed at each visit. Documentation specifically related to the review of psychiatric medications was not on the physician form.
All required documentation related to the reason/amount/effectiveness of the prescribed psychiatric medication will be documented every 3 months by the prescribing physician. |
02/28/2024
| Implemented |
6400.166(b) | Individual #1 is prescribed GNO Senna Plus 8.6-50mg tablet. Take one tablet by mouth twice a day as needed. This medication was administered on 2/4/24, 2/7/24, 2/11/24, 2/13/24, 2/14/24, 2/17/24, 2/18/24 and 2/25/24. The medication administration record did not include the time that the medication was administered on these dates. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Director of Residential Services reviewed the proper documentation requirements with the staff responsible for the error. |
03/03/2024
| Implemented |
|
|
SIN-00183480
|
Renewal
|
03/30/2021
|
Compliant - Finalized
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|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.166(a)(7) | The Medication Administration Record (MAR) did not list the dose of the medication Lisinopril prescribed for Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The MAR was updated to list the dose of the medication Lisinopril for Individual #1 |
04/01/2021
| Implemented |
6400.166(a)(8) | The Medication Administration Record (MAR) did not list the route of administration for the medication Lisinopril prescribed for Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The MAR was corrected to list the route of administration for the medication Lisinopril prescribed for Individual #1 |
04/01/2021
| Implemented |
6400.166(a)(9) | The Medication Administration Record (MAR) did not list the frequency of administration for the medication Lisinopril prescribed for Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The MAR was updated to list the frequency of administration for the medication Lisinopril prescribed for Individual #1. |
04/01/2021
| Implemented |
6400.166(a)(11) | The Medication Administration Record (MAR) for Individual #1 did not document a diagnosis or purpose for the following medications: Cetirizine Hcl, Ziprasidone Hcl, Metoprolol Succinate ER, Lisinopril, Topiramate, Acetaminophen ER, Oxybutynin Cl Er, Senna Plus, Diclofenac Sodium 1% Gel and Balmex Complete Protection. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The MARS documented the purpose for medications. on a line separate from the medication. There were 2 medications on each MAR with diagnosis #1 corresponding to medication #1. Diagnosis 2 corresponded to medication # 2. New MARS were created with one medication and purpose per sheet. |
04/01/2021
| Implemented |
|
|
SIN-00166289
|
Renewal
|
11/25/2019
|
Compliant - Finalized
|
|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The license for this chapter expires on 12/15/2019. A self-assessment wasn't completed until 11/13/2019. | 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 agency¿s certificate of compliance, to measure and record compliance with this chapter.
| UCP of NE PA will 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 our certificate of compliance.
((management staff were trained on the requirements of this regulation 11/26/19 -CH 12/18/19)) |
12/03/2019
| Implemented |
|
|
SIN-00109705
|
Renewal
|
03/01/2017
|
Compliant - Finalized
|
|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.213(1)(i) | The record for Individual #1 did not include information regarding identifying marks. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | The record for individual #1 has been corrected with N/A noted in response to the section: information regarding identifying marks.
In the future all records will note if there are identifying marks or N/A if there are no identifying marks. |
04/06/2017
| Implemented |
|
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SIN-00069754
|
Renewal
|
11/06/2014
|
Compliant - Finalized
|
|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(f) | There are 2 handicapped accessible exits in the home, only 1 is being used for fire drills. | Alternate exit routes shall be used during fire drills. | The program specialist will monitor the use of the second exit during fire drills. The residential coordinator will review fire drills on a monthly basis to assure both exits are used. |
11/06/2104
| Implemented |
|
|
SIN-00219588
|
Renewal
|
02/14/2023
|
Compliant - Finalized
|
|
SIN-00147613
|
Renewal
|
01/09/2019
|
Compliant - Finalized
|
|
SIN-00127887
|
Renewal
|
01/29/2018
|
Compliant - Finalized
|
|
SIN-00087814
|
Renewal
|
02/09/2016
|
Compliant - Finalized
|
|
SIN-00055909
|
Renewal
|
10/03/2013
|
Compliant - Finalized
|
|