| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no self-assessment completed for the home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| DSS CEO, Program Specialist and HR Resource is scheduled to meet to complete the agency¿s Self-Assessment for this location on 10/14/22. |
10/30/2022
| Implemented |
| 6400.21(b) | Staff #1 who was hired on 5/17/22 did not have an FBI check completed prior to working with individuals | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| HR Specialist reviewed staff #1 HR file and found that staff #1 was a resident of PA in the past 2 years prior to working with individuals. HR Specialist addressed this on 10/3/22 by having staff #1 sign an affidavit stating that she was in fact a resident of PA in the prior two years. No further action is needed. |
10/03/2022
| Implemented |
| 6400.64(a) | The basement main living area space have windowsills that are covered in dust, debris and dead bugs. | Clean and sanitary conditions shall be maintained in the home. | As of 9/1/22, the basement windowsills have been cleaned and no longer have dust, debris and dead bugs. Dusting the windowsills will be put on the staff chore list to be dusted every week by staff. |
09/01/2022
| Implemented |
| 6400.64(b) | There are cobwebs and numerous dead bugs under the window air conditioner in the basement window. | There may not be evidence of infestation of insects or rodents in the home. | As of 9/1/22, maintenance cleaned under the window air conditioner in the basement and there are no longer cobwebs or dead bugs. Dusting the windowsills under the air conditioner will be put on the staff chore list to be dusted weekly by staff. |
09/01/2022
| Implemented |
| 6400.66 | There is no light in the basement laundry area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| As of 9/20/22, Maintenance repaired the light receptacle in the basement laundry area. |
09/20/2022
| Implemented |
| 6400.67(a) | The first floor bathroom wall tile is peeling and chipping across the entire bottom side perimeter. | Floors, walls, ceilings and other surfaces shall be in good repair. | As of 9/20/22, Maintenance removed the peeling and chipping tile from the entire bathroom |
09/20/2022
| Implemented |
| 6400.67(b) | Individual #2 has a cushion used for sitting, that has the stuffing coming out of it. This individual is incontinent and frequently soils items after sitting on them, thereby creating a potential infectious disease hazard . This cushion needs to be replaced. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 9/1/22, House Manager replaced chair cushion with a new chair cushion for individual#2 |
09/01/2022
| Implemented |
| 6400.67(b) | The basement main living area windowsill surface is chipping heavily into pebble like pieces. | Floors, walls, ceilings and other surfaces shall be free of hazards. | As of 9/20/22, Maintenance repaired the windowsill surface in the basement and there is no longer chipping debris in that area. |
09/20/2022
| Implemented |
| 6400.72(b) | The basement back door, leading to the rear driveway, needs a frame foundation replacement. The current frame foundation is box-packing Styrofoam which fills the gap between the door frame and the house foundation. | Screens, windows and doors shall be in good repair. | As of 9/20/22, DSS maintenance repaired the frame foundation around the basement back door. |
09/20/2022
| Implemented |
| 6400.76(c) | Throughout the home, specifically on the living room wall and individual #1's bedroom ceiling, there are spots that have been patched up but not repainted to match the rest of the paint surrounding the patched up surface. | Furniture shall be comfortable and home-like. | CEO will put in a maintenance request to make repairs to individual #1¿s bedroom ceiling. |
11/30/2022
| Implemented |
| 6400.104 | There was no notification provided to the fire department for the home. | 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.
| CEO updated the notification letter to be sent to the fire department for this location. A copy was emailed on 10/3/2022. CEO is waiting for letter to be signed and sent back. CEO will follow up to ensure letter is received. |
10/03/2022
| Implemented |
| 6400.141(c)(13) | Individual #1's physical dated 7/27/22 did not indicate allergies on the form. | The physical examination shall include: Allergies or contraindicated medications. | Program Specialist will contact Individual#1¿s PCP to request that they update their physical form to include individual #1¿s allergies if applicable |
10/30/2022
| Implemented |
| 6400.142(f) | There is no dental plan for either individual 1 or 2 in the record. There is a schedule for dental services but no plan detailing what supports she needs in the hygiene process if any. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | As of 9/1/22, Program Specialist created a dental plan for individual #1 and #2. The dental plans have been added to the program books so that the supporting staff is aware of their specific needs. Staff have been trained on how to implement the individuals dental plan.
The Program Specialist will update the individual's dental plan as needed and will ensure that it is added to the program books. |
09/01/2022
| Implemented |
| 6400.144 | Individual #1 prescribed PRN medication docusate sodium senna tablet 8.6 mg, used to treat constipation was not present in the home. | 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.
| On 9/1/22 Individual #1 medication was reviewed by CEO/medication trainer, it was found that the PRN was present onsite however the medication was prescribed under a different name. CEO updated the MAR to reflect the correct name of the medication. |
09/01/2022
| Implemented |
| 6400.151(c)(3) | Staff 2's annual physical dated 1/27/21 did not include medical problems or communicable disease information. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | HR Specialist will review Staff #2¿s physical form and contact PCP to get the physical form updated to include medical problems and indicate any communicable diseases. |
10/30/2022
| Implemented |
| 6400.171 | Juice, water and packaged snacks were being stored in a basement pantry closet on the floor next to a mouse trap. | Food shall be protected from contamination while being stored, prepared, transported and served.
| As of 9/1/22, House Manager moved juice, water and snacks off the closet floor and put them on the shelf in the closet. |
09/01/2022
| Implemented |
| 6400.181(a) | Individual #1 and2's record does not contain a clear and concise assessment. There are areas that have been assessed, however the regulatory standard on assessments have been omitted in the following areas:
Strengths, needs,
Likes, dislikes, interests
Acquisition of functional skills
Communication
Personal adjustment
knowledge of heat sources
lifetime medical history
recommendations
progress and growth in all areas
knowledge of water safety and ability to swim | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program Specialist will transfer information for individual #1 and #2 to the agency¿s appropriate Annual Assessment form. |
10/30/2022
| Implemented |
| 6400.62(b) | The living room contained an unlocked cabinet which stored Jergens lotion and body wash. At least one person in this home, individual #2 needs to have all substances locked away as there is a history of ingesting these types of non-edible items, per their ISP. | 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. | As of 9/1/22, CEO purchased a file cabinet to store dangerous substances that are to be locked away per the ISP of at least 1 individual.
As of 9/28/22, All staff were retrained and instructed to keep dangerous substances locked away per individual #2 ISP. |
09/01/2022
| Implemented |
| 6400.163(h) | Individual #1's prescribed PRN medication Systane eye drops expired on 11/2021 and was still present in the medication box. There was not a current medication present in the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 8/30/22 Individual #1 medication was reviewed by CEO/med admin trainer, it was found that the PRN Systane medication had expired and was removed from the med box. |
08/30/2022
| Implemented |
| 6400.165(c) | Individual #'s medication review revealed the following discrepancies:
-Prescribed medication mycophenolate 250 mg states on MAR to take 1 capsule 2 times daily, however the label states to take 4 capsules every 12 hours.
-Prescribed medication prednisone 5 mg states on MAR to take 1 tablet daily, however the label states to take 4 tablets daily.
-Prescribed medication envarsus 1 mg states on MAR to take 2 tablets daily, however the label states to take 3 tablets daily.
-Prescribed medication envarsus 4 mg states on MAR to take 1 time a day, however the label states to take 2 times a day.
-Prescribed medication fludrocortisone .1 mg states on MAR to take 1 time a day, however the label states to take 2 times a day.
-Prescribed medication magnesium oxide 400 mg states on MAR to take 2 tablets twice daily, however the label states to take 2 tablets three times daily.
-Prescribed medication midodrine 5 mg state on MAR to take 2 times a day, however the label states to take three times daily. | A prescription medication shall be administered as prescribed. | On 9/1/22 Individual #1 medication was reviewed by CEO/medication trainer and Program Specialist. CEO and Program Specialist contacted individual#1¿s pharmacist to review their medication list and request new prescriptions that reflected the doctor¿s current instructions and agency MAR. |
09/01/2022
| Implemented |
| 6400.213(1)(i) | Individual #2's record did not list religion, The space on the form was left blank. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Program Specialist will update individual#2¿s record to list their religion. |
10/10/2022
| Implemented |