| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-Assessment not completed (submitted to licensing but form is blank in its entirety). | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Moving forward PC will complete self assessment form 3 to 6 months prior to inspection according to regulation. |
03/21/2021
| Implemented |
| 6400.21(a) | Staff member #'1's date of hire was 6/28/19 criminal history record check completed 11/20/19. criminal history check not completed within the required timeframe. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees 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. | PC will insure all background checks will be done before date of hire. |
03/05/2020
| Implemented |
| 6400.46(f) | Staff member #2's initial fire safety training was conducted 12/30/19 and the staff started working with individuals on 11/23/19. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | PC will conduct all required training prior to the new employee start date. |
03/06/2020
| Implemented |
| 6400.64(a) | There was dust buildup beside the dryer, and in the bottom vents of the refrigerator and in the ceiling vents in the hallway. | Clean and sanitary conditions shall be maintained in the home. | PC will continue thorough cleaning in all areas that accumulates dust |
03/06/2020
| Implemented |
| 6400.66 | The back door light at the exit was not working, it needs to be replaced
The second back door exit, the light did not have a light bulb in it. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| After speaking with the owner the lighting on the side of the house and in the back of the house is dust til dawn and only work during those times. |
03/05/2020
| Implemented |
| 6400.76(a) | The blinds in the vacant bedroom were broken and taped, should be replaced
The bedroom mattress springs in individual#1's bedroom were at the surface of the mattress at the touch. Mattress should be replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | PC will a sure that all necessary furniture will be acceptable according to regulation. The program specialist will do a monthly check to ensure all physical site issues are dealt with. |
09/01/2020
| Implemented |
| 6400.77(b) | There was no tape or antiseptic found in the first aid kit. | 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. | PC will make sure the first aid kit will have all the necessary items in the first aid kit |
03/05/2020
| Implemented |
| 6400.104 | The letter to the fire department was not updated when an individual moved out on January 19,2019. Individual #1 lived alone in the home until 7/29/19. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| PC will notify the current letter to indicate the names and location of individual's room to the Aston fire department. |
03/11/2020
| Implemented |
| 6400.110(g) | The Fire drills conducted on 1/17/2020, 2/5/2020 indicated that the upstairs smoke detector was inoperable on the fire drill form. No documentation of repairs found during inspection. | If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. | PC is working with the owners of the house on the hard wire connection repair however, PC to the liberty of adding a battery operated smoke detector until hard wire connection is repaired, |
03/10/2020
| Implemented |
| 6400.112(c) | According to the fire drill records, the smoke detector in the attic was not operable on the following days 2/20/19, 6/13/19, 7/29/19, 8/29/19, 10/9/19, 11/21/19, 12/29/19, 1/17/20, 2/5/20
The Fire drill conducted on 4/9/19 did not list problems during evacuation and the amount of time it took to evacuate
The Fire drill conducted on 7/29/19 the exit route to evacuate was not listed
The Fire drill conducted on 9/25/19 did not list the time it took to evacuate.
The Fire drill conducted on 10/9/19 did not list the amount of time to evacuate, and the exit route taken to evacuate.
The Fire drill conducted on 1/17/2020 did not list the time, and that the upstairs smoke detector as inoperable. | 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. | PC will keep written fire drill record of the date. time, and the amount of time it took for evacuation, the exit route used, and if there were any problems with the fire alarm and smoke detector. |
09/01/2020
| Implemented |
| 6400.112(e) | One sleep drill was conducted on 6/13/19, and no other sleep drills were completed. | A fire drill shall be held during sleeping hours at least every 6 months. | PC will conduct one sleep drill twice a year, every six months. |
06/24/2020
| Implemented |
| 6400.113(a) | It could not be determined if individual #1 annual fire safety training was completed on 12/30/19, because it did not contain fire drill responsibilities and designated meeting place training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | PC will make sure that the individual will be trained in all areas of fire and safety, evacuation, responsibilities during fire drills and the location of the designation meeting places. |
09/01/2020
| Implemented |
| 6400.141(c)(3) | Individual #1's physical exam completed on 9/24/18 left blank the immunizations section. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | PC will make sure during the physical examination the physician will complete the immunization section of the physical form. |
09/01/2020
| Implemented |
| 6400.141(c)(10) | Individual #1's physical exam completed on 9/24/18 left blank the communicable disease section. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | PC will make sure that the communicable disease section is filled out completely by the physician |
09/01/2020
| Implemented |
| 6400.141(c)(14) | Individual #1's physical exam completed on 9/24/18 left blank the information pertinent to diagnosis in case of an emergency section. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | PC will make sure all pertinent information will be complete by the physician on the physical form. |
09/01/2020
| Implemented |
| 6400.142(f) | Individual #1's record did not have 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. | PC will contact the dental office to confirm the individual's dental hygiene independence. after which the individual's hygiene status will be updated in his ISP. |
09/01/2020
| Implemented |
| 6400.151(c)(2) | The Physical exam for staff member #2 dated 11/26/19 did not include the type of Tuberculin test that was conducted, and it could not be determined the date the test was administered. | 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. | PC will make sure Tuberculin testing will have the date of testing and the date of result. |
03/09/2020
| Implemented |
| 6400.168(d) | It could not be determined at inspection if the annual medication administration practicum was completed for staff members #1, 5, and 6 only the initial medication training was provided. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | PC staff's medication observation was completed. In addition to having a electronic copy PC will also have a paper copy in the office. |
03/09/2020
| Implemented |
| 6400.181(e)(7) | 12/7/19 Assessment does not tell individual #1's ability to sense and move away from heat sources which exceed 120 degrees Fahrenheit | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment will indicate individual #1 awareness of heat source which exceed 120 F. |
04/27/2020
| Implemented |
| 6400.181(e)(8) | The Assessment dated 12/7/19 does not indicate individual #1's ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Individual #1 assessment was completed on 12/6/2019, stated that individual #1 is fully aware of the evacuation process in case of an emergency or fire. PC will update there form to reflect fire evacuation assessment. |
04/27/2020
| Implemented |
| 6400.181(e)(13)(i) | The Assessment dated 12/7/19 does not address individual #1's progress for last 365 days in any area. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| PC will add a health section to individual #1 assessment to indicate annual health updates. |
04/27/2020
| Implemented |
| 6400.217 | Individual #1`'s record did not have a current or previous signed consent. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Individual #1 has a signed consent in his records, PC will make sure individual #1sign and understand the consent form annually. |
03/06/2020
| Implemented |
| 6400.31(b) | Individual #1's record did not have a previous or current signed copy of rights. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Individual #1 signed off on his individual rights after training and understanding his individual rights. The program specialist will ensure all rights are explained and signed timely. |
03/06/2020
| Implemented |
| 6400.46(b) | The Fire safety expert credentials were requested, but not provided during the inspection. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | PC will obtain the credentials from the fire safety trainer, a copy of the trainer's credential will be on file at the main office for future training. |
09/01/2020
| Implemented |
| 6400.167(a)(1) | Individual #1Medication Simvastatin 10mg tablet -take one tablet by mouth at bedtime 8 pm dosage on 3/4/2020 listed as "o" on medication log-staff states individual was not in the home at the time. But same was not indicated on medication log. it could not be determined when or if the medication was administered. | Medication errors include the following: Failure to administer a medication. | All staff will be retrained on the correct way to document when an is away on a family visit. |
09/01/2020
| Implemented |
| 6400.169(d) | Medication log reads-Check blood glucose Monday and Friday twice a day (8am & 10am)- staff initials #1, and #4 on medication log-no record of diabetes training provided for these staff members.
Medication log reads-Check Blood glucose on Wednesday's after dinner- staff initials #1 -no record of diabetes training-requested, but not provided at inspection | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | All trainings will be updated annually and kept at the residence and office, with the date, source and name of trainer documented, |
09/01/2020
| Implemented |
| 6400.186 | In 7/2019 ISP the only outcome is to assist individual #1 in finding a job and no documentation exists of the effort made to assist in this goal. | The home shall implement the individual plan, including revisions. | Individual #1 ISP will be revised with two new goal focusing on Health and Socialization. |
09/01/2020
| Implemented |