Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(c) | The written fire drill records were not available for the fire drills held from 1/1/19 to 9/30/19. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | UCIP's office at 17999 Cussewago Road, Meadville PA 16335. experienced a fire on 9/18/19. Records of completed monthly fire drills for the Blooming Valley location were kept in this office and were destroyed. Program Specialist Matt Morian has records of fire drills done on 9/30/19, 10/15/19, 11/26/19 and 12/18/19. Program Specialist Matt Morian will continue to complete and document fire drills monthly according to what is outlined in the regulations set by ODP. [Immediately and upon hire, the CEO or designee shall educate all staff persons responsible for conducting, documenting and maintaining records on the procedures of maintaining written fire drill records to include all required information. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
6400.141(a) | Individual #1 does not have a physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | [Individual #1] 's Primary Care Physician was contacted by Program Specialist Matt Morian and documentation of Richard's physical form 8/6/19 was recovered. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current physical examination. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
6400.141(c)(6) | Individual #1 does not have Tuberculin testing. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | [Individual #1]'s Primary Care Physician office was contacted by Program Specialist Matt Morian and documentation of Richard's TB test and results were recovered. [Individual #1]'s TB test was administered on 8/3/18. Results were read on 8/6/18 and were negative. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
6400.142(a) | Individual #1 does not have a dental examination. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | [Individual #1]'s original dental exam was lost in facility fire on 9/18/19. Program Specialist Matt Morian contacted Medical provider and received [Individual #1]'s dental exam that was done 7/29/19. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
6400.151(a) | Direct Service Worker #1 does not have a physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Michelle Bly's physical documentation was recovered by HR Director Patti Capron. Michelle has a physical completed on 3/13/18. [Immediately, the CEO or designee shall audit all staff persons' records to ensure all staff persons have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
6400.151(c)(2) | Direct Service Worker #1 does not have Tuberculin testing. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Michelle Bly's TB results were recovered from TB Administrator at Vernon Place Medical facility. The test was administered on 3/13/18. Results were read on 3/15/18 and were negative.[Immediately, the CEO or designee shall audit all staff persons' records to ensure all staff persons have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
6400.181(a) | Individual #1 does not have an assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Due to [Individual #1]'s original assessment being lost in facility fire on 9/18/19 an additional assessment was completed on 12/23/19 by Program Specialist Matt Morian and sent to [Individual #1]'s team. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current assessment. Missing assessments shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
6400.163(h) | Triamcinolone Acetonide .1% cream, apply sparingly topically 2 times a day for 14 days prescribed to Individual #1 was discontinued on 10/31/19; remained in Individual #1's medication storage box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medication was removed from the home on 12/19/19 and stored at the UCIP office building until UCIP Nurse Holly Cardy disposed of the medication on 1/7/20. [Immediately and continuing at least monthly, the CEO or designee shall audit all individual medications, medications administration records and physicians' orders to ensure all individuals are administered medications prescribed and documented as required and discontinued or expired medications are destroyed in a safe manner according to Federal and State statutes and regulations. Immediately, upon hire and continuing at least annually, the CEO or designee shall educate all staff person responsible for medication administration of the agency's policies and procedures for ensure prescription medications that are discontinued or expired are destroyed in a safe manner according to Federal and State statutes and regulations. Documentation of trainings shall be kept as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |