| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #1, date of hire 4/25/2022, had a state criminal history check submitted on 7/19/2022. [Repeat Violation, 12/2/2021] | 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.
| During a quarterly review of personnel records, it was discovered that direct service worker #1, date of hire 4/25.2022 did not have a criminal history check submitted. On July 19, 2022 a criminal history check was submitted.
All personnel records were reviewed and criminal history checks were submitted as needed. |
02/01/2023
| Implemented |
| 6400.64(a) | At 10:22AM on 11/18/2022, there was a thick, dark brown liquid in the bottom drawer of the refrigerator in the kitchen of the home. | Clean and sanitary conditions shall be maintained in the home. | Residential Manager removed and disposed of all expired food.
All refrigerators were checked and all expired food was removed and disposed of as needed. |
12/16/2022
| Not Implemented |
| 6400.64(b) | There is an ordinate amount of gnats in the kitchen and in the bathroom on the second floor of the home. | There may not be evidence of infestation of insects or rodents in the home. | KZL Agency has contacted Lobos Management, and have put in a Maintenance Ticket for them to come and the evidence of infestation of insects in the home. (see attached)
KZL Agency will follow-up weekly until the maintenance ticket is completed. |
12/14/2022
| Not Implemented |
| 6400.72(b) | The left side of the window in Individual #1's bedroom is broken and covered by cardboard held in place with duct tape. There is not a screen on the right side of this window. | Screens, windows and doors shall be in good repair. | KZL Agency has contacted Lobos Management, and have put in a Maintenance Ticket for them to come and address Individual #1's left side broken window and the missing screen on the right side.(see attached)
KZL Agency will follow-up weekly until the maintenance ticket is completed. |
12/14/2022
| Not Implemented |
| 6400.77(c) | The first aid kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | Residential manager put a new copy of manual in first aid kit.
All first aid kits were checked and copy of manual was placed as needed. |
12/16/2022
| Implemented |
| 6400.80(a) | The walkway and steps leading to the front door of the home have broken concrete pavers and detached bricks posing a possible tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | KZL Agency has contacted Lobos Management, and have put in a Maintenance Ticket for them to come and address the walkway and steps leading to the front door of the home have broken concrete pavers and detached bricks posing a possible tripping hazard. (see attached)
KZL Agency will follow-up weekly until the maintenance ticket is completed. |
12/14/2022
| Not Implemented |
| 6400.101 | There is a turn lock on the the basement side of the door between the basement and the garage: posing an obstruced egress from the garage when engaged. There is not a ''man door" inside the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The turn lock on the basement side door between the basement and garage posing an obstructed egress from the garage when engaged was replaced.
All basement doors were checked and door knobs were replaced as needed. |
12/16/2022
| Not Implemented |
| 6400.112(c) | The written fire drill records for the fire drills conducted on 5/18/2022 and 6/11/2022 do not address problems encountered. This section was left blank. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | An electronic fire drill was created and implemented for December fire drills. The fire drill record includes the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. A comment section is included that will required documented before the fire drill documentation can be saved. |
12/16/2022
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed on 7/26/2022, does not include medical 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. | Residential Manager faxed Individual #1's physical examination, completed on 7/26/2022, and requested the doctor complete medical information pertinent to diagnosis and treatment in case of an emergency.
Residential Manager will follow-up to ensure documentation was sent back to KZL Agency. |
12/15/2022
| Not Implemented |
| 6400.171 | At 10:22AM on 11/18/2022, there were two chicken wings wrapped inside a paper towel on the top shelf of the refrigerator. There were green peppers and another, unknown vegetable covered in what appeared to mold in the bottom crisper drawer of the refrigerator. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Agency purchased food covers, new containers and markers for properly storing and labeling food in houses.
All refrigerators were checked to ensure food was protected from contamination while be being stored. |
12/16/2022
| Not Implemented |
| 6400.181(e)(4) | Individual #1's assessment, completed 6/1/2022, does not address the individual's need for supervision. | The assessment must include the following information: The individual's need for supervision.
| The assessment has been updated to show supervision requirements on the front page so that staff is able to easily locate the information. (see attached)
All assessments will be updated accordingly. Please see attached document. |
12/12/2022
| Not Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 6/1/2022, does not include recommendations for specific areas of training, programming and services. [Repeat Violation, 12/2/2021] | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment has been updated to show supervision requirements last page so that staff is able to easily locate the information. (see attached) |
12/12/2022
| Not Implemented |
| 6400.214(b) | The most current copy of the Individual #1's assessment is not kept at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Copies of all assessments were placed in the homes to ensure that all staff can view the assessments and accurately know the abilities of the individuals. |
12/12/2022
| Not Implemented |
| 6400.32(r)(1) | Individual #1 has a key lock on her bedroom door. The individual has not been provided with a key or entry mechanism to unlock the door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | The key lock on Individual #1's bedroom door was replaced, and Individual #1 has been provided with a key to unlock the door.
All individual bedroom doors were checked and and key locks were replaced as needed, and all individual's have been given a key to unlock their doors. |
12/16/2022
| Implemented |
| 6400.32(r)(5) | On 11/18/22, the direct service worker providing services to Individual #1 did not have access to a key to unlock Individual #1's door. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | The key lock on Individual #1's bedroom door was replaced, and staff has been provided with a key to unlock the door.
All individual bedroom doors were checked and and key locks were replaced as needed, and staff have been given access to a key to unlock their doors. |
12/16/2022
| Implemented |
| 6400.163(d) | At 10:16AM on 11/18/2022, Individual #1's prescription medications, Polyethylene Glycol 3350, Olopatadine Sol 0.2% was on the desk inside the living room of the home. At 10:30AM on 11/18/2022, a paper bag of blister packs containing expired prescription medications belonging to individuals that do not reside in the home were inside the closet in bedroom #2. The bedroom door and the closet door were unlocked and accessible to Individual #1. There is a medication dispenser inside a shelf in the living room with two pills inside labeled for an individual who does not reside at the home. This shelf is accessible to Individual #1. [Repeat Violation, 12/2/2021] | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Individual #1's prescription medication Polyethylene Glycol 3350, & Olopatadine Sol 0.2% was immediately placed in the locked area with the rest of the medications.
The blister packs containing expired prescription medications belonging to another individual, along with the medication dispenser were immediately removed from Individual #1's home, and disposed of according to KZL Agency's policy. |
12/16/2022
| Not Implemented |
| 6400.163(h) | At 10:30AM on 11/18/2022, a paper containing blister packs of expired medications belonging to individuals who do not reside in the home were in the closet of bedroom #2. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The blister packs containing expired prescription medications belonging to another individual, along with the medication dispenser were immediately removed from Individual#1's home and disposed of following KZL Agency's medication disposal policy.
All medications in all KZL Agency homes were reviewed and any expired medication was removed and disposed of immediately. |
12/16/2022
| Not Implemented |
| 6400.166(a)(4) | Individual #1's November 2022 Medication Administration Record does not include the name of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Residential manager added medication to Individual #1's MAR that includes the name of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. |
12/16/2022
| Not Implemented |
| 6400.166(a)(5) | Individual #1's November 2022 Medication Administration Record does not include the strength of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Residential manager added medication to Individual #1's MAR that includes include the strength of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. (see attached) |
12/16/2022
| Not Implemented |
| 6400.166(a)(6) | Individual #1's November 2022 Medication Administration Record does not include the dosage form of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Residential manager added medication to Individual #1's MAR that includes include the strength of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. (see attached) |
12/16/2022
| Not Implemented |
| 6400.166(a)(7) | Individual #1's November 2022 Medication Administration Record does not include the dose of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Residential manager added medication to Individual #1's MAR that include the dose of Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. |
12/16/2022
| Not Implemented |
| 6400.166(a)(8) | Individual #1's November 2022 Medication Administration Record does not include the route of administration for Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Residential manager added medication to Individual #1's MAR that include the route of administration for Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. |
12/16/2022
| Not Implemented |
| 6400.166(a)(9) | Individual #1's November 2022 Medication Administration Record does not include the frequency of administration for Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. [Repeat Violation, 12/2/2021] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Residential manager added medication to Individual #1's MAR that include the frequency of administration for Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. (see attached) |
12/16/2022
| Not Implemented |
| 6400.166(a)(11) | Individual #1's November 2022 Medication Administration Record does not include the diagnosis or purpose for Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Residential manager added medication to Individual #1's MAR that include the diagnosis or purpose for Olopatatdine Sol. .2% Eye Drops and Triamcinolone 0.1% Cream. (see attached) |
12/16/2022
| Not Implemented |