Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.21(a) | Criminal Background check was not completed until 4/13/2021 and the staff #3 was hired on 1/8/2021. The criminal background check must be submitted within 5 days of hire. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| We have provided the entire agency staff with the New Employee Check List for New Hires, as our primary Administrative Staff who implemented that process was out sick due to Covid-19. This process has now been updated for compliance wit the regulation timeframe within 5 days of date of hire. |
05/18/2021
| Implemented |
6400.62(a) | There was a bottle of Clorox bleach located in the kitchen cupboard of the basement kitchen. Staff reports that the basement door is always locked. At the time of the inspection the basement door was not locked. Poisons shall be locked up. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Agency utilized 2 Administrative Staff for the video walk through of the homes with the ODP Inspector on the phone. This house was unoccupied as staff and individuals were in the community for activities. Admin Staff 1 entered empty house with phone video operating with ODP Inspector on the call, Admin Staff 2 entered house several minutes after Staff1. Admin Staff 1 asked Admin Staff 2 to unlock all doors, the medications and the First Aid Kit for the inspection process. We first went over the medications that had been placed on the kitchen table, the first aid kit, and then proceeded to complete the walk through. In the future we will maintain keeping all areas and items locked until the inspector is at the lock location to view the key unlocking the door and items. |
04/22/2021
| Implemented |
6400.141(c)(1) | The individual physical exam should include the medical history. | The physical examination shall include: A review of previous medical history. | The agency is including the previous medical history, per regulation's, within the document itself rather than attachments that accompany the document. Correction specific to this individual as well as agency wide to every individual in care. |
05/18/2021
| Implemented |
6400.141(c)(9) | The individual physical exam should include a prostrate exam being that individual #1 is over 40 years old. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The agency is ensuring that edited version of the Annual Individual Physical is utilized for greater clarity in the performance of medical services for this and all individuals in care moving forward. In this case the Prostate Examination was recorded by the PCP on another form for the same date. The previous check system on the Physical itself recorded prostate as normal but revision of the document will provide greater clarity. |
05/18/2021
| Implemented |
6400.181(d) | The annual assessment should include signatures of the program specialist and individual | The program specialist shall sign and date the assessment. | The agency has secured the Program Specialists signature on this and all other Individual's annual assessments with the transmittal letter to the Individual as proof that the individuals were made aware of the results of the assessment. |
05/18/2021
| Implemented |
6400.166(a)(10) | Individual #1 is prescribed Erythromycin OD and the MAR states to apply 1cm to both eyes once weekly on Saturday at bedtime. The time listed on the MAR is 8am. The pharmacy label does not specify a designated time. The MAR directions contradicts with times. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The error specific to time listed on the Medication Administration Record has been corrected for this individual and we reviewed all other individual's MAR's for possible errors, none found. The Admin Review Team has been made aware and will proceed with a heightened vigilance to reviewing this area. |
05/18/2021
| Implemented |
6400.166(d) | The directions of the prescriber shall be followed. The individual's medication Erythromycin does not specify what time of the day it shall be administered on the MARS. | The directions of the prescriber shall be followed. | The error specific to time of day on the Medication Administration Record has been corrected for this individual and we reviewed all other individual's MAR's for possible errors, none found. The Admin Review Team has been made aware and will proceed with a heightened vigilance to reviewing this area. |
05/18/2021
| Implemented |