| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | An application for a PA criminal record check was submitted to the State Police for the following staff but the staff was hired prior to the 5 working days required:
NAME: Staff #1- 12 DAYS
DATE OF HIRE: 8/4/2021- 08/16/2021
NAME: Staff #2 - 11 DAYS
DATE OF HIRE: 8/5/2021 - 08/16/2021
NAME: Staff #3 - 14 DAYS
DATE OF HIRE: 8/2/2021- 08/16/2021
NAME: Staff #4- 14 DAYS
DATE OF HIRE: 8/2/2021 -- 08/16/2021 | 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.
| The Human Resources Director has updated our staff file checklist on September 27, 2021 (see attached) to ensure we distinguish between date of application, date of hire, and date staff began initially working with an individual in order to clarify the time frame in which the staff persons obtained the Criminal History Check. MJHC Human Resources Director has also updated our staff qualification policy (see attached) on September 27, 2021 to ensure our policy specifically states that an application for a Pennsylvania Criminal History Record Check will be submitted to the State Police for prospective employees of the home who will have direct contact with the individuals, including part-time and temporary staff persons prior to hire but no later than within 5 working days after the persons date of hire. |
09/27/2021
| Implemented |
| 6400.82(e) | The shower located in the basement did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | The Quality Assurance staff has purchased and placed a nonslip surface mat in the shower located in the basement of the home. (See attached photo). |
09/17/2021
| Implemented |
| 6400.111(c) | The fire extinguisher located in the kitchen did not meet the requirements which is a 2A rating. The fire extinguisher in the kitchen was a 1A rating. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The CEO purchased new 2A-10BC rated fire extinguishers which were placed and serviced in the home on 10/28/2021 (see attached photo). |
10/28/2021
| Implemented |
| 6400.141(a) | It cannot be determined that individual #1 received a physical within a year prior to their admission date of 8/16/21. The agency provided a physical from 7/6/20 that lists a negative TB test with a read date of 7/8/20. They also submitted a medical evaluation dated 3/16/21 and a hospital discharge exam dated 5/27/21, neither of which constitute a physical as they are both missing components required by regulation 141c. The 3/16/21 document is missing information pertinent to diagnosis in case of an emergency; special diet considerations; allergy information; an indication that medical history was reviewed; vision and hearing screenings; OB/GYN, mammogram, and PAP exam information; information on physical limitations; immunization history; and an assessment of health maintenance needs. The 5/27/21 document is missing many of the same items and considerations: a record of immunizations; mammogram and PAP exam information; physical limitation information; vision and hearing screening information; and medical information pertinent to diagnosis in case of an emergency. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 was admitted into our residential program on 8/16/21. She completed a physical examination on 10/25/2021. During the physical examination the individual reused to have a GYN Exam, Mammogram Exam, and Labs completed. As stated on the form (see attached) the physician documented ¿deferred¿ in those areas. |
10/25/2021
| Implemented |
| 6400.142(f) | Individual #1 file does not contain a dental hygiene plan. | 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. | The Individual was admitted into our program on 8/16/21. The Dental Hygiene Plan was created on 9/27/21 for Individual #1 (see attached). |
09/27/2021
| Implemented |
| 6400.144 | It could not be determined if individual #1 is receiving medication as prescribed. Medication is not being monitored, there is no way to know if medication is being given based on the agencies administering system. Medication Lorazepam 0.5 mg Tablet shows on the MAR as administered on 09/16/2021, however when the blister pack was viewed the medication was present and not administered for that dose on 09/16/2021. Agency provided another zip lock bag and stated the medication was taken from that bag. All PRN's are administered everyday to Ind. #1, no order from a doctor or pharmacy showing these meds are to be administered daily. | 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.
| MJHC Program Specialist reviewed all medications and MAR on 9/17/2021 to ensure all medications are listed correctly on MAR. |
09/17/2021
| Implemented |
| 6400.212(b) | It cannot be determined who completed individual #1 ,lifetime medical history document, as it was not signed and dated. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| The Lifetime Medical History for Individual #1 was updated and signed and dated on 10/28/2021. |
10/28/2021
| Implemented |
| 6400.163(a) | There was no pharmacy label on Controlled medication (MORPHINE SYRINGE, also for medication HALOPERIDOL) which both medications were stored in zip lock bags / not in original prescribed packaging. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | A pharmacy label was provided by the hospital on 9/20/2021 for Morphine SU SOL 100MG/5ML (20MG/ML) and Haloperidol LAC 2 MG/ML CONC (see attached photo). The medications come directly to MJHC from Enclara Pharmacy Inc. They do not provide the original packaging as we have requested. However the label has the exact quantity included for the syringes in which any usage can now be documented on the MAR. |
09/13/2021
| Implemented |
| 6400.165(c) | The medication for Ind. #1 MORPHINE SULFATE ORAL SOLUTION 100MG states on the label to take every 4 hours as needed which matches the MAR for the individual, the new prescription provided to the agency is listed as MORPHINE SULFER 15mg Tablet states take by mouth every 12 hours. This medication and dosage is Not listed on the individual's MAR. | A prescription medication shall be administered as prescribed. | MJHC Program Specialist reviewed all medications and MAR on 9/17/2021 to ensure all medications are listed correctly on MAR. |
09/17/2021
| Implemented |