| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Pennsylvania Criminal Background Checks were submitted late for several new hires. | 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.
| Provider administrator updated the providers hiring protocol to ensure background checks are completed timely. |
12/22/2022
| Implemented |
| 6400.22(a) | The agency failed to keep up-to-date financial record of the individuals reviewed which include and up to personal funds and including rights to manage their own funds. It could not be determined if the agency is charging the individuals 72% of the room and board. Also, documentation, by actual receipts or expense records indicating what funds were given directly to the individuals are unclear. There seems to be commingling of the individual's personal funds with the homes, agency and other individuals. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | Provider accountant ensures that each individual maintains his or her personal bank account for use of their funds after deduction of room and board.
The provider has implemented individual financial binders and continue charging 72%of the maximum of SSI or 72% of the available SSI amount.
Provider has conducted a retraining of Policy on individual funds management. |
01/26/2023
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | 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. | A thermometer was made available on the site on 12-20-2022. |
12/20/2022
| Implemented |
| 6400.151(a) | The most recent physical for Staff #2 is dated 1/27/2020. Staff physicals need to be done every 2 years. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff 2 completed annual physical on 12-20-22. |
12/20/2022
| Implemented |
| 6400.151(a) | The physical for Staff #3 is dated 11/14/22, which is 8 months after the staff member's March 2022 date of hire. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Provider administrator updated the providers hiring protocol to ensure pre-employment physical is provided at hiring. |
12/21/2022
| Implemented |
| 6400.151(a) | The most recent physical for Staff #4 is dated 8/26/2020. This is to be completed every 2 years. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff completed physical on 1-26-23 but final review by physician and form completion scheduled for 2/28/23 pending result of other blood testing. |
02/28/2023
| Implemented |
| 6400.151(c)(2) | TB skin test with a negative result for staff #1 was last completed 09/25/2019 and read on 09/27/2019. Current test via x-ray was not done until 06/13/2022 rendering the test late as it surpasses the 2-year testing requirement. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Provider updated employment requirements to ensure expectations are communicated to staff. |
01/27/2023
| Implemented |
| 6400.151(c)(3) | Staff #3's physical does not indicate if they are free of communicable diseases. | 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. | Provider implemented a uniform physical form to accurately capture all required information. |
01/03/2023
| Implemented |
| 6400.15(b) | The agency is not using the appropriate self-inspection tool. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Provider has replaced the current self-inspection tool with the department approved licensing inspection tool. |
12/20/2022
| Implemented |
| 6400.46(b) | There is no fire safety training for Staff #2, Staff #3, or Staff #4. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Provider has replaced its online fire safety course with a training conducted by a fire safety expert. |
03/03/2023
| Implemented |
| 6400.165(g) | Individual #4 must be seen by a psychiatrist every 90 days to ensure his psychotropic medications are compliant. | 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. | A medical visit plan form has been implemented by provider Program specialist to ensure all psychotropic visits are properly documented by individual #4 doctor.
An appointment has been scheduled with individual #4 psychiatrist for 02-27-23.
Correction status is ongoing.
Target date 02-27-23 |
02/27/2023
| Implemented |
| 6400.169(a) | Staff #1 has not successfully completed a department-approved medication administration course renewal. Agency provided a certificate of completion dated 12/06/2021, no record of the date, name of the trainer and documentation that the course was completed was provided. | 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). | Provider replaced online Modified Medication Administration completed on myodp.org by employees with an in-person training conducted by an ODP certified trainer.
Provider has updated its training policy / curriculum to include in person medication training in place of the ODP online modified training. |
12/22/2022
| Implemented |
| 6400.213(1)(i) | Individual #4's photo needs to be dated and clear to identify the individual. | 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 updated individual # 4 face sheet including a most recent picture taken 11-29-22. |
12/21/2022
| Implemented |