Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00200274 Renewal 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill conducted on 8/4/21 did not indicate the time it took for evacuation.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. Staff will be retrained on how to complete the fire drill form correctly and within the time specified as required by the Compliance Regulatory Guide. 02/21/2022 Implemented
SIN-00184889 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 has been prescribed medication to treat symptoms of a psychiatric illness, and the reviews of medications completed on 10/09/20, 12/3/20, 2/4/21, and 3/4/21 do not have a diagnosis or reason for prescribing Invega 3mg.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.Plan of Correction for: PA § Code 6400.165(g) Prescription Medications How it was corrected: On March 29, 2021, Quality Adult Care Services Program Specialist Supervisors and Quality Compliance Specialist revised the medication review form to add a disclaimer regarding the requirement of the diagnosis and reason for prescribing the medication to be identified per 6400.165(g). (see attached form) When it was corrected: March 29, 2021 Who made the correction: Quality Adult Care Services Quality Compliance Specialist and Program Specialist Supervisors. What specific change will be made: The medication review form was revised to add in highlight the disclaimer per 55 PA § Code 6100.465.11 indicating the diagnosis and reason field must be completed for all prescribed medication. A footer will be added to the form with the corresponding of the appointment. The diagnosis and reason field and the medication continuance section were also highlighted to bring awareness to the section. (see attached) Who will make the change: Quality Adult Care Services Program Specialist Supervisors When will the change be made: Change will be completed March 29, 2021. How will the change be made: Quality Adult Care Services management team was retrained on the PA Code 6400 and 6100 Regulations to review the requirements. Program Specialist Supervisors will revise the each individual¿s receiving psychiatric medication forms to add in highlight the disclaimer per 55 PA § Code 6100.465.11 indicating the diagnosis and reason field must be completed for all prescribed medication. A footer will be added to the form with the corresponding date of the appointment. The diagnosis and reason field and the need for medication continuance section were also highlighted. (see attached). 03/29/2021 Implemented
SIN-00169428 Renewal 01/15/2020 Compliant - Finalized