Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.77(b) | REPEAT from 1/4/2021 annual inspection: At the time of the 3/10/22 onsite inspection, the first aid kit was not equipped with scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Scissors have been added to the first aid kit |
05/04/2022
| Implemented |
6400.104 | The most recent letter to the local fire department, dated 9/20/21, only indicates that one resident, Individual #2, is in the home and may need assistance. There are two individuals who reside in the home and the letter isn't clear as where Individual #2's bedroom is located. | 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.
| Fire letter has been updated to clarify where BOTH individuals bedrooms are and resent to the fire department. |
05/09/2022
| Implemented |
6400.141(c)(9) | Neither a prostate exam nor a Prostate-Specific Antigen (PSA) test was conducted for Individual #1 at their 6/2/21 physical examination appointment. | The physical examination shall include: A prostate examination for men 40 years of age or older. | PCP has completed this portion of the annual physical to explain why a prostate exam was not completed. |
04/11/2022
| Implemented |
6400.141(c)(14) | Individual #1's 6/2/2021 physical examination record did not include information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | PCP has completed this information on the physical examination. |
05/02/2022
| Not Implemented |
6400.46(d) | Staff person #2 was trained by the National CPR Foundation in first aid, CPR, AED on 11/28/18 and not again until 1/5/2021, outside the 2-year certification window described on their certificate. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #2 will redo First Aid/CPR training. |
05/27/2022
| Implemented |
6400.51(b)(5) | Staff persons #1 and #2 have worked directly and independently with Individual #1 over the previous year. There are no records maintained that Staff person #1 was oriented to Individual #1's individual-specific plans, protocols, health needs, services, behavior support plans, financial management skills, food and dietary needs, etc. Additionally, there are no records that any individual-specific trainings included an in-person training component. | The orientation must encompass the following areas: Job-related knowledge and skills. | Staffs #1 and #2 will redo orientation, which will also include an in-person component. |
05/27/2022
| Implemented |
6400.52(a)(1) | Staff person #1 has worked directly with Individual #1 over the previous year. There are no records maintained that Staff person #1 received any training hours during the agency's annual training year from 7/1/2020-6/30/2021.
Staff person #3 only completed 21 hours of annual training within the annual training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staffs #1 and # are back on track with two hours of training per month. |
05/27/2022
| Not Implemented |
6400.52(c)(2) | Staff person #3's annual training did not include all of the required elements defined in 6400.52(c)(2). | The annual training hours specified in subsections (a) and (b) must encompass the following areas: 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. | Staff #3's training for the rest of the year will be sure to include the required components. |
05/27/2022
| Implemented |
6400.165(g) | Individual #1's 9/3/2021 review of their psychotropic medications does not include the diagnosis or reason for prescribing the psychotropic medications. The review stated the medication was prescribed for "HTN", which is the medical abbreviation for "hypertension" and not the reason for Individual #1's medication prescribed to treat a psychiatric illness. | 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. | Appointment forms have been updated to include a spot for physician to complete including reason for prescribing the medication. |
05/02/2022
| Implemented |
6400.166(b) | During the 3/10/22 onsite inspection, it was discovered that the date and time of medication administration, and the name and initials of the staff person who administered Individual #1's morning medications on 3/10/22 was not recorded at the time of administration. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Write up was completed for staff member who had not immediately signed off on MARs following medication administration to client. Staff was retrained on MAR protocol. |
03/21/2022
| Implemented |
6400.169(a) | Staff person #2 was documented that they were certified via the Department's annual medication administration training course on 8/28/2020 and not again until 9/2/2021, outside the annual time frame requirements. There are no records maintained that additional medication training was completed for Staff person #2 due to their late medication recertification. According to the course, only one mar was completed by 8/28/2021, so an additional two mars were required to recertify the staff. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #2 will undergo the required additional medication training. |
05/27/2022
| Implemented |