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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | Individual #1 had Tuberculin skin testing by Mantoux method with negative results 12/22/20 and then again 2/2/23. | 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 physical examination shall include: Tuberculin skin test by Mantoux method with a negative result 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.
An electronic appointment tracker has been added to Individual #1' s electronic record. This tracker will notify the House Manager, by changing the color of the cell , 3 months prior to the compliance date Alerting the House Manager to schedule the Tuberculin Skin Testing. |
07/31/2023
| Implemented |
| 6400.181(a) | Individual #1 had an annual assessment completed 9/7/21 and then again 10/17/22. | 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. | 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.
An electronic Assessment Tracker will be used by the Program Specialist. This tracker will alert the Program Specialist by turning red 30 days prior to the date of compliance. |
08/01/2023
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained their individual rights 1/1/22 and then again 1/19/23, | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The home shall inform and explain individual rights and the process to report a rights violation to the individual and persons designated by the individual, upon admission to the home and annually thereafter.. On 7/24/2023 the House Managers compiled a list of all residents and the 2023 date of the individual rights review and signature. The individual rights will be administered to the residents 365 days from the 2023 administration of the individual rights with no grace period. |
08/01/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat psychiatric illness. The medication reviews completed 1/20/23 and 4/24/23 did not include the names of the medications or the necessary dosages. [Repeat Violation: 8/2/22 et. al] | 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. | Medications prescribed to treat symptoms of a psychiatric illness shall be reviewed by a licensed physician at least every 3 months to include: reason for prescribing the medication, the need to continue the medication and the dosage. Prior to attending either a video or in person medication check appointment the House Manger will print a consultation form from individual #1's electronic medical record. This consultation form reflects the medications, dosages and reason the medication is administered. The physician will review both the consultation form along with either the video or in person medication form for signature, for each medication check appointment. The forms will be uploaded to the electronic medical record . |
08/01/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(a) | Individual #1 had a dental examination on 5/14/21, and then again on 7/19/22, exceeding the annual requirement. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Staff will schedule next annual dental exam at the time of completion of the current annual dental exam, to be compliant and within the 380-day period. The annual appointments are entered into the electronic medical record system (EMR). [Training form, dated 9/19/22, on the requirements of dental examinations was received on 9/23/22 and reviewed 9/28/22. Monthly appointment audit template for House manager and Quarterly appointment audit template for Program Specialist received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. |
09/30/2022
| Implemented |
| 6400.51(b)(1) | Direct Services Worker (DSW) #1, date of hire 6/15/22, did not complete orientation training prior to working alone with individual and within 30-days of hire in the following training topic: The application of person-centered practices, community integration, Individual choice, and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | DSW#1 did complete her orientation training by 6/21/2022, and never worked a shift alone with an individual during this time or any time after. DWS#1 failed to complete all necessary post orientation trainings in the 30 day period and was terminated. [Documentation of completed training topic for Direct Services Worker #1 requested, but was not provided. Training form, dated 9/20/22, on the requirement that orientation training include the topic of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships was received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. |
09/30/2022
| Implemented |
| 6400.51(b)(2) | Direct Services Worker (DSW) #1, date of hire 6/15/22, did not complete orientation training prior to working alone with individual and within 30-days of hire in the following training topic: the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adult Protective Services Act, the Child Protective Service Law, the Adult Protective Services Act, and applicable protective service regulations. | The orientation 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. | DWS#1 did complete on 6/21/22, Identifying, preventing and reporting abuse, neglect and exploitation. DSW#! has never worked alone with an individual . DWS#1 failed to complete all necessary trainings in the 30 day period and was terminated. [Documentation of completed training topic for Direct Services Worker #1 requested, but was not provided. Training form, dated 9/20/22, on the requirement that orientation training include the topic of 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 was received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. |
09/30/2022
| Implemented |
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