Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Cleaning products were unlocked and accessible in the cabinet under the kitchen sink. Individual #1's individual plan last updated, 5/26/22, states that cleaning products are kept locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials were locked up and or made inaccessible to individuals in the 284 Bruceton site. Residential House Managers and Program Specialists will review ISP and Assessments to ensure correlation. They will sign off that they have read both ISP and Assessments once every three months. Program Specialists will attend an Assessment Training with the Program Director on 11/9/2022. The Assessment meeting and training will cover the following
PROGRAM SPECIALIST ASSESSMENT MEETING
AGENDA
DATE OF MEETING: 11/9/22
¿ BIG IDEA BEHIND THE ASSESSMENTS
o WHO THEY ARE FOR:
¿ PARTICIPANTS
¿ STAFF
¿ SC
¿ FAMILIES AND OTHER TEAM MEMBERS
o WHY THEY ARE DONE
¿ GOALS
¿ SUPPORTS THAT ARE REQUIRED/ RECOMMENDED
o WHEN THEY ARE DONE
¿ WHO SHOULD BE INVOLVED
¿ PROVIDING COPIES
o RECOMMENDATIONS
¿ AUDITS
o CHECKING FOR ACCURACY
The Programs Specialists will complete an ISP training through ODP by 11/15/2022. |
11/18/2022
| Implemented |
6400.66 | The light outside the basement exit underneath the back deck of the home is inoperable. There was no other source of lighting in this area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Residential House Manager was able to submit a maintenance ticket for the light fixture to be fixed. The light fixture was fixed. |
11/11/2022
| Implemented |
6400.112(c) | The written fire drill records for the fire drills conducted on 7/24/2022 and 8/22/2022 did not document the amount of time it took for evacuation. [Repeat Violation, 11/19/2021] | 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. | Program Specialists have been appointed the point people for Fire Drills. The Program Specialists will ensure fire drills are conducted and the paperwork is completed in it's entirety.
In total we will conduct at least four fire drills within this POC (12/15/2022) to ensure the residents are aware of what to do at this site. The Program Specialists will check the paperwork from the drill within 48 hours to ensure details of the fire drill are being documented. Quality and Compliance Coordinator will attend the 284 Bruceton House meeting on 11/8/2022 at 4:30pm and review the regulation
(a) An unannounced fire drill shall be held at least once a month.
(b) Fire drills shall be held during normal staffing conditions and not when additional staff persons are present.
(c) 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.
(d) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.
(e) A fire drill shall be held during sleeping hours at least every 6 months.
(f) Alternate exit routes shall be used during fire drills.
(g) Fire drills shall be held on different days of the week and at different times of the day and night.
(h) Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.
(i) A fire alarm or smoke detector shall be set off during each fire drill.
55 Pa. Code § 6400.112
All staff will sign off on this at the meeting on 11/8/2022 at 4:30pm. |
12/22/2022
| Implemented |
6400.181(e)(12) | Individual #1's assessment, completed on 1/7/22 did not include recommendations. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Director and Assistant will assist the Program Specialists in completing the initial Assessment by 12/1/2022 this Program Specialists will be retrained on Assessments on 11/9/2022. The assessment training will cover the following....
PROGRAM SPECIALIST ASSESSMENT MEETING
AGENDA
DATE OF MEETING: 11/9/22
¿ BIG IDEA BEHIND THE ASSESSMENTS
o WHO THEY ARE FOR:
¿ PARTICIPANTS
¿ STAFF
¿ SC
¿ FAMILIES AND OTHER TEAM MEMBERS
o WHY THEY ARE DONE
¿ GOALS
¿ SUPPORTS THAT ARE REQUIRED/ RECOMMENDED
o WHEN THEY ARE DONE
¿ WHO SHOULD BE INVOLVED
¿ PROVIDING COPIES
o RECOMMENDATIONS
¿ AUDITS
o CHECKING FOR ACCURACY |
12/01/2022
| Implemented |
6400.15(b) | The agency completed a self-assessment of the home on 4.29/2022; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Old versions of the self-assessment tool were shredded and discarded. Staff were asked to complete the self-assessment on the correct version this will be completed by 11/22/2022
The correct version of the Self Assessment Tool was sought out by new Quality and Compliance Coordinator and supplied by inspector. All expired versions of the Self Assessment Tools were erased off the internal databases by Quality and Compliance Coordinator. Updated version was placed on internal site by direction of IT. |
11/22/2022
| Implemented |
6400.44(b)(1) | Individual #1's assessment, completed 1/7/22, indicates on page 9 that Individual #1 safely uses or avoids poisonous materials independently and on page 10 indicates that Individual #1 requires physical assistance to use and store cleaning products safely and appropriately. | The program specialist shall be responsible for the following: Coordinating the completion of assessments. | The Program Specialists will create an addendum to the assessment with the correct information after attending an Assessment Training by the Program Director on 11/9/2022. The Program Specialists will also complete a training through ODP on ISP's by 11/15/2022. |
11/15/2022
| Implemented |
6400.165(b) | Individual #1's prescribed medication, Calcium Chewable tablets, was not present at the home. | A prescription order shall be kept current. | The Residential House Manager and Program Director were able to order medication to have on hand at the site on 10/20/2022. |
12/19/2022
| Implemented |
6400.165(g) | A psychiatric medication completed 9/15/22 for Individual #1 did not include the need to continue prescribed medications. [Repeat Violation, 11/19/2021] | 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. | The Program Specialist has been in contact with the physician that was able to continue the prescription and order for medication. |
12/19/2022
| Implemented |
6400.166(a)(11) | Individual #1's October 2022 Medication Administration Record does not include the diagnosis or purpose for Kurvelo, Calcium tablets and Vitamin D3 tablets. | 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 MAR has been corrected by the Residential House Manager on the date of the inspection 10/20/2022. |
12/19/2022
| Implemented |
6400.166(b) | Individual #1 is prescribed Clonzaepam 1mg Tab with instructions to take 1 tablet by mouth twice daily. This medication was not initialed as administered on 10/5/2022 at 9PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The controlled count was checked by the Residential House Manager and Program Director. It was deemed the medication was given and not signed for. This is a medication documentation error that will be addressed in a full medication training. All direct care staff, residential House Manager, Assistant Program Director and Program Specialists will be retrained in Medication Administration by 12/19/2022. |
12/19/2022
| Implemented |