Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.21(a) | Staff number 2: The date of hire is noted as 6/4/2022 and the criminal history check was requested on 6/20/22. This request date is greater than 5 days after date 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.
| The clearance for staff #2 was run in accordance with the regulation. Staff #2's hire date was 6/24/2022 (ATTACHMENT #1). The Pennsylvania State Police Response for Criminal History was run and disseminated on 6/20/2022, four days prior to her start date (ATTACHMENT #2). This information was shared with the licensing inspectors at the time of the exit review when it was discovered that there was an error when reviewing this information during the licensing visit (ATTACHMENT #3) |
11/21/2022
| Implemented |
6400.64(b) | There were four flies flying around the home during the physical site inspection. | There may not be evidence of infestation of insects or rodents in the home. | Quarterly Extermination services occur at this location, with a scheduled treatment occurring on 12/15/22. Associate Director contacted exterminating company and has increased service to this location on a monthly basis, effective January 19, 2023. |
12/15/2022
| Implemented |
6400.65 | The second floor bathroom is ventilated by a skylight in the ceiling; however the skylight was not operational at the time of inspection. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Lead staff person contacted the landlord on 11/22/22 to report this as a maintenance issue. Landlord responded promptly and arranged for repair on 12/8/22 and was verified to be working by Associate Director on 12/8/22. |
12/08/2022
| Implemented |
6400.110(e) | The smoke detectors in this three story home operated independently but were not interconnected with each other. | 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. | Associate Director determined that the smoke detectors were not interconnected due to the Lead staff changing all of the batteries in the smoke detector due to Day Light Savings and this resulted in the system not being in connected. Associate Director corrected the issue immediately on 11/21/22 and verified that the smoke detectors were connected. |
11/21/2022
| Implemented |
6400.144 | Individual #2's prescribed medication aprepiant 80 mg, with directions to take as needed for nausea was not present in the home for this individual to self-medicate with if needed. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The individual in this home self-medicates and was aware that this was no longer an active PRN medication and shared this information with the licensing inspector. The Associate Director immediately confirmed with individuals¿ prescribing doctor that this medication was discontinued (ATTACHMENT # 8) and individuals¿ medication profile was updated to reflect this information on 11/21/22- the day the error was identified. |
11/21/2022
| Implemented |
6400.181(c) | Individual number 2 2/22/22 assessment does not list the sources of its information. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | A review of the Assessments completed for all individual's supported within the agency was reviewed and it was determined that this particular assessment was the only one missing the sources of information. This is an oversight of completion by the Community Support Liaison. The correction was made on this assessment after confirming the sources used to complete it and updated in the individuals¿ record. |
12/02/2022
| Implemented |
6400.165(g) | Greater than 90 days elapsed between Individual #2's 5/13/22 and 9/12/22 medication management appointments, a period of 122 days between them. | 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 appointment that was scheduled in 5/12/22 was not attended due to the individual refusing to attend and another appointment was not available until 6/13/22. The rescheduled medication management appointment was attended on 6/13/22 and the individual has successfully attended all follow-up medication management appointments since that time. |
01/16/2023
| Implemented |