| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | On 2/20/20, at 10:14 AM, the hot water temperature measured at 122.3 degrees Fahrenheit at the bathtub in the bathroom on the second floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On 2/27/20 a scald guard has been installed at the Fleming CLA. Southside Plumbing set the scald guard at 118 degree for the maximum degrees. The temperature was taken again and the temperature was below 120 degrees. Immediately and at least weekly until hot water temperatures do not exceed 120°F and then continuing at least monthly, hot water temperature shall be measured at all bathtubs and showers in all community homes. Documentation of measurements shall be kept and reviewed at least quarterly by designated management staff person. Within 30 days of receipt of the plan of correction all staff person responsible for measuring hot water temperature shall be trained on the policies and procedures to ensure hot water temperatures in bathtubs and showers do not exceed 120°F at all times. Documentation of trainings shall be kept. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff on this requirement within 30 days. |
04/23/2020
| Implemented |
| 6400.110(e) | The home has three stories including a basement. The smoke detectors in the home are not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | : The new wireless interconnected fire alarms were installed at the Fleming CLA. During monthly fire drills staff will document that they are working properly. Randomly on a month basis the Program Specialist will check the fire alarms to assure that they are working properly. This will be documented and done for 1 year. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff on this requirement within 30 days. |
04/23/2020
| Implemented |
| 6400.111(a) | On 2/20/20, there was not a fire extinguisher in the basement of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The fire extinguisher was present but it was behind the basement door and was not in visual site. The fire extinguisher was moved from behind the door and placed under the sink where it is visible to all staff and clients. During monthly fire drills staff will check off that there are fire extinguishers on each floor. This will also be checked by the Program specialist on a monthly basis to assure that the fire extinguisher is present. Documentation will be kept for 1 year. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff on this requirement within 30 |
04/23/2020
| Implemented |
| 6400.141(c)(6) | Individual #1 had a Tuberculin testing completed on 1/15/18 and then again on 2/06/20. | 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. | The Program Specialist created a white board in the Fleming office to make sure all appointments will be in compliance with the regulations. The chart has the dates when appointments are due for each individual and the date of the appointment. The Program Specialist added a TB column on the chart. This chart will be updated on-going to assure all appointments and required tests are completed within the regulations. . At least quarterly for 1 year, the site supervisor shall review a 25% sample of completed appoint summaries to ensure aforementioned process is working. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff within 30 days. [Documentation of trainings and audits shall be kept. (DPOC by AES,HSLS on 3/17/20)] |
04/23/2020
| Implemented |
| 6400.212(b) | Individual #1's assessment completed be the program specialist on 11/6/19 was not signed or dated by a program specialist. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| The Supervisor reviewed the 55 PA Code Chapter 6400.212(b) regulation that address¿s the assessment with the Program Specialist. Moving forward the person in charge of making sure the assessment is completed is a Team Lead by Title but has the credentials/job description to be the Program Specialist at the site. The Team Lead was informed that moving forward he is to sign the form as the Program Specialist, not the Team Lead. The Supervisor will do a 25% random sampling of the assessments on site to assure that the Program Specialist is following the regulation. This training will be completed by 3-24-2020. All Program Specialists will be retrained by 3-24-2020 on the requirement to sign all assessments and all pertinent documents as the Program Specialist not using their agency title of Team Lead.[During the aforementioned audit, the reviewer shall ensure all entries in individuals' records are legible, dated and signed by the person making the entry. (DPOC by AES,HSLS on 3/17/20)] |
04/23/2020
| Implemented |
| 6400.62(b) | On 2/20/20, at 10:12AM, a 32 fluid ounce bottle of 409 All Purpose Cleaner with precautions reading "contact poison control if ingested" was in the unlocked cabinet below the sink in the kitchen of the home. Individual #2's ISP, last updated 1/3/2020, states "poisonous substances need to be locked to ensure [his/her] safety." | Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment. | All staff was educated on ISP trained and importance of locking poisonous substance according to 55 PA Code Chapter 6400.62(b) for the health and safety of the individuals living at the Fleming CLA. The Program specialist did a safety check of the substances after the training and made sure any chemicals were locked up. Since the client was assessed to be not able to distinguish between poisonous or non-poisonous substances. Signs will also be posted in the house to remind staff to lock poisonous materials up after being used. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff within 30 days. |
04/23/2020
| Implemented |
| 6400.165(g) | Individual #1 had a review medications prescribed to treat symptoms of a diagnosed psychiatric illness on 4/29/19 and then again on 8/07/19. | 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. | 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 will be in compliance with the regulations. The chart has the dates when appointments are due for each individual and the date of the appointment. At least quarterly for 1 year, a designated staff person shall review a 25% sample of psychiatric medication review documentation to ensure timeliness and all [Documentation of audits shall be kept. (DPOC by AES,HSLS on 3/17/20)] |
04/23/2020
| Implemented |
| 6400.166(b) | Quetiapine 50mg, take 1 tablet by mouth daily and Clonazepam 0.5mg tablet, take 1 tablet by mouth daily prescribed to Individual #1 were not initialed as administered at 3:00PM on 2/19/20. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Program Specialist/Medication Trainer reviewed the 5 rights of medication administration with the staff that did not initial and put the count down on the MAR. The trainer had the staff sign off that the training was completed. At least weekly for 1 month and then continuing monthly, a designated staff person shall review all individuals' current medication records and current medications to ensure all individual are being administered medications as prescribed and documented as required for the health and safety of the individuals. Documentation of reviews shall be kept. This training will be completed by 3-24-2020. The Program Specialist will retrain all staff within 30 days |
04/23/2020
| Implemented |