| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There were dirty leave allover the floor of the back porch. There were mildew around the base of the shower tiles in the adaptive bathroom. | Clean and sanitary conditions shall be maintained in the home. | The leaves were removed on 02-21-18. The mildew was removed from the base of the shower, removed all caulk, scraped grout lines and caulked shower on 03-27-18. Shower was cleaned by DSP. It is the responsibility of the Direct Support Professionals, Team Manager and Program Manager to report repairs in facilities electronic work order system. Repair request are completed by sub-contractor and monitored by Residential Assistant Director. |
03/27/2018
| Implemented |
| 6400.76(a) | There was mildew on the outside/patio furniture and cushion. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The mildew on the patio furniture was removed and cushions were replaced with new cushions on 3-27-18. It is the responsibility of the Direct Support Professionals, Team Manager and Program Manager to report repairs in facilities electronic work order system. Repair request are completed by sub-contractor and monitored by Residential Assistant Director. |
03/27/2018
| Implemented |
| 6400.141(c)(7) | Individual #1's physical exam dated 9/13/17 did not include a comprehensive GYN examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 had a UROGYN appointment on 7-6-18. This was not a comprehensive GYN examination. Individual #1 had comprehensive GYN exam on 5-16-18 (next available date). The Team Manager for the Chester County POD which includes Sickle began on 2-12-18. Included in her responsibilities is to: ensure medical appointments are completed following the medical appointment process. Job description and responsibilities were reviewed with Team Manager by Human Resources on 2-12-18. |
05/16/2018
| Implemented |
| 6400.144 | Nasal Decon spray 0.5% prescribed for Individual #1 was to be administered as thus: Two sprays in each nostril twice a day. However, the medication was not administered beyond 2/11/18. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual #1 was diagnosed with Flu type A on 2/7/18. She was prescribed the nasal spray which started on 2-7-18 and ended 2/11/18. The MAR was correct. The medication should have been removed by the Direct Support Professional and given to the nurse for disposal. Procedure was reviewed with DSP¿s by Program Manager. |
02/26/2018
| Implemented |