| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(f) | Staff person #2's most recent fire safety training was completed on 11/18/15. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff person #2 is signed up to receive the missing fire safety training on 4/21/17. Staff person #2 was verbally reminded that fire safety training needs to be completed within 365 days to ensure compliance with regulations. Going forward the Director, Case Management is making training a reoccurring agenda item for her monthly Program Specialist meetings. She will remind her staff at those meetings who is due the following month and monitor to ensure compliance. |
04/21/2017
| Implemented |
| 6400.46(i) | Staff person #2's most recent First Aid and CPR training was completed on 11/18/15. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff person #2 is signed up to receive the missing CPR and First Aid training on 4/21/17. Staff person #2 was verbally reminded that CPR and First Aid training needs to be completed within 365 days to ensure compliance with regulations. Going forward the Director, Case Management is making training a reoccurring agenda item for her monthly Program Specialist meetings. She will remind her staff at those meetings who is due the following month and monitor to ensure compliance. |
04/21/2017
| Implemented |
| 6400.62(a) | The closet in bathroom #9 had Degree deodorant, moisture barrier cream unlocked. The closet in bathroom #2 had Degree deodorant unlocked. The closet in bathroom #46 had Degree deodorant, moisture barrier cream, and Kleenex antibacterial foam skin cleanser unlocked. The closet in bathroom #39 had poisons including personal hygiene products and Coppertone sunscreen unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Locks were installed in the bathrooms by the Woods maintenance department. (see attachment) The Residential manager or designee will complete monthly environmental inspection of the residence to ensure areas are in compliance. Any issues of non compliance noted will be forwarded to the Residential Director who will follow up with the Woods maintenance department. |
02/21/2017
| Implemented |
| 6400.110(f) | Individual #3 cannot hear the alarm, and bathrooms #2, #9, and #46 did not have strobe lights. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | A proposal was sent out to replace the strobes in Heatherwood in 4 wing bathrooms and the kitchen bathrooms. (see attachment) The projected date of completion is 4/5/17. It was found that the bathrooms were remodeled and during the remodeling the strobes were removed for painting and never put back up. Going forward, the Residential Manager will ensure that all strobes are replaced or put back up during any remodeling efforts if taking down by notifying the Fire Safety Manager. |
04/05/2017
| Implemented |
| 6400.141(c)(14) | Individual #2's annual physical examination dated 8/10/16 did not contain information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Nursing department revised the physical form to include information pertinent to diagnosis or treatment in case of an emergency. As new physicals are completed, the new form will be utilized. (see attachment) |
02/13/2017
| Implemented |
| 6400.181(e)(14) | Individual #1's annual assessment dated 10/17/16 did not document the individual's ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual #1's assessment was revised to include her ability to swim. (see attachment) Swimming abilities will be clearly stated in the residential assessments going forward. |
02/23/2017
| Implemented |
| 6400.186(b) | Individual #1's three month ISP review dated 12/1/15-2/29/16 was not signed by the program specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The program specialist signed the ISP review on 4/4/17. (see attachment) Going forward, the Program Specialist will submit the assessment to either the Director of Program Coordination or the Program Planning Coordinator who will review and ensure that the assessment is signed prior to it being sent to the records department. |
04/04/2017
| Implemented |
| 6400.213(1)(i) | Individual #2's record did not document hair color, eye color or 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. | Individual #2's assessment was revised on 4/3/17 to include hair color, eye color and identifying marks. (see attachment) This information will be included in all residential assessments going forward. |
04/03/2017
| Implemented |
| Article X.1007 | Woods Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 - 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #1's hire date of 9/30/16 and their criminal history check was completed after on 10/4/16. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Although the clearance was not processed until 10/4/16, staff person #1 was in orientation at that time and never had contact with any of the individuals served at Woods. Their Childline clearance and FBI clearance both came back prior to their start with working with individuals and indicated that they did not have a record. In the future all criminal history checks will be completed prior to the date of hire for all new staff. |
03/31/2017
| Implemented |