| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The needs of residents in the home indicate that poisons should be locked. At the time of inspection, a spray can of Claire Disinfectant Spray Q was found in the cabinet under the left sink of one of the main bathrooms in the hallway of the home. Label directions indicated to "Call Poison Control" if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 11.13.23 disinfectant spray was removed at the time of inspection from under the sink and locked in the appropriate closet. |
11/13/2023
| Implemented |
| 6400.80(b) | At time of inspection an outlet on the partially enclosed outdoor space at the rear exit of the home did not have a protective cover/face plate exposing internal wiring. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Maintenance department put a face plate on the outlet. |
11/13/2023
| Implemented |
| 6400.104 | Individual #1 was officially admitted into the program on 6/1/23. Assessment for Individual #1 dated 6/13/23 indicates that they are rated a "1" for "responds to fire alarms." A "1" indicating that "Requires constant assistance. The Individual would not complete the objective without assistance." Individual #1 is documented to require assistance with ambulation, noted to use a "stroller" and is in process of obtaining a physician ordered "walking vest." There was no notification to the fire department notifying them of the admission and required assistance during fire drills of Individual #1.
The fire department shall be notified of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire, this includes physical and verbal assistance. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Residential supervisor sent updated notification letter to the local fire department on 11.14.23 to include individuals' ability to evacuate. |
11/14/2023
| Implemented |
| 6400.110(f) | At time of inspection on 11/14/23 the bed shaker in place for Individual #2 did not activate or sound when the interconnected smoke detector system was tested. The bed shaker would activate when tested individually but did not alert when the interconnected smoke detectors were sounded. | 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. | The non operable bed shaker was replaced with a new bed shaker device. |
11/14/2023
| Implemented |
| 6400.51(a)(2) | There was to documentation to support that Staff #1 had completed training on The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations as required. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Dietary, housekeeping, maintenance and ancillary staff persons. This provision does not include a person who provides dietary, housekeeping, maintenance or ancillary services, if the person is employed or contracted by the building owner and the licensed facility does not own the building. | Employee was notified of missing training and completed the abuse training on 11.16.23 |
11/16/2023
| Implemented |
| 6400.166(b) | At time of inspection on 11/13/23 the November Medication Administration Record (MAR) for Individual #1 did not include the initials of the staff administering the 8pm doses of Famotidine and Chlorhexidine on 11/9/23 and 11/10/23. The dated blocks to record initials were blank. A reason for the lack of initials or administration was not provided. The name and initials of the person administering the medication shall be recorded at the time the medication is administered.
At time of inspection the pharmacy label and November 2023 Medication Administration Record (MAR) entry for Melatonin prescribed to Individual #1 directs that "Take one tablet by mouth at 8pm for sleep insomnia." Individual Support Plan last updated on 7/28/23 for Individual #1 indicates that "must have all (except for the vitamin d, which is given orally) of their medications administered to them through their g-tube." Additional Provider generated documentation notes that "I take my medication through my G-tube." Evidence indicates that the medication is being crushed and administered through the G-tube. The route of administration is not being recorded on the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All medications will be signed for after administration in accordance with the Med Adm Training. |
11/14/2023
| Implemented |