| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff person #1's date of hire was on 12/5/16, and the criminal history check was completed on 1/18/17. Staff person #3's date of hire was on 4/10/17, and the criminal history check was completed on 8/16/14. | 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.
| A new Criminal history check has been requested for staff#1 on 12/18/17 and Staff # 3 on 12/29/17. A copy of the final reports received from the State Police and the FBI is kept on their record. Human Resource Manager will be responsible to ensure 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. A tracking sheet has been created to prevent future occurrences. Attachment #10,#11 |
12/18/2017
| Implemented |
| 6400.21(b) | Staff person #2 hired on 9/15/17 did not live in Pennsylvania for the past 2 years, and did not have an FBI clearance completed. | If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. | A new Criminal history check has been requested for staff#2 on 11/17/17 whiles we wait for the result. Human Resource Manager will be responsible to ensure If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. A tracking sheet has been created to prevent future occurrences. Attachment #12 |
11/17/2017
| Implemented |
| 6400.22(e)(3) | Individual #1's spending money did not have receipts for spending over $15.00. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | All receipts have been accounted for and filed properly. Programs Specialist, supervised by Financial Controller will ensure all receipts and expense record, of every single purchase exceeding 15 dollars made on behalf of all individuals carried out by or in conjunction with a staff person. Financial Controller or designee will conduct monthly audits of financial records to ensure receipts are present for purchases of 15 dollars or more.attachment 2 |
11/20/2017
| Implemented |
| 6400.46(b) | Staff person #2 was hired on 9/13/17 and completed orientation on 9/16/16, but there was no training syllabus. | The home shall have a training syllabus describing the orientation specified in subsection (a). | Staff person#2 hired on 9/13/17 never worked in the group home. His file was mistakenly placed among the group home staff files. There is a training syllabus describing the orientation specified in subsection (a). HR Manager placed Staff person#2's file among the files to be audited for the group by mistake. His file has been sorted out into the appropriate files. Moving forward the HR Manager will be present at the time of audit to sort out required files for employees that work specifically in a group home. |
11/17/2017
| Implemented |
| 6400.81(k)(6) | Individual #2's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | Individual #2's bedroom now has a mirror. Providence Home Care Agency will ensure that In all bedrooms, each individual shall have a mirror. House Managers will conduct weekly checks to ensure each individual rooms has a mirror. Quality Assurance Manager will be responsible for all new and old individual homes by conducting monthly self-assessments to ensure continuous compliance. attachment#9 |
11/17/2017
| Implemented |
| 6400.101 | The door leading to the garage had a key lock to exit the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The door leading to the garage had no key lock to exit the home. This issue has been fixed. Moving forward Providence Home Care Agency will ensure that stairways, halls, doorways, passageways, and exits from rooms and from the building shall be unobstructed. Quality Assurance Manager will be responsible for all new and old individual homes by conducting monthly self-assessments to ensure continuous compliance. attachment#8 |
11/17/2017
| Implemented |
| 6400.111(a) | There was no fire extinguisher in the basement. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | A fire extinguisher is placed in the basement. Providence Home Care Agency will ensure that there shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. House Managers will be responsible to conduct every weekly inspection to ensure fire extinguishers are allocated in each location, and tags are up to date to prevent future occurrences. Quality Assurance Manager will have oversight of the groups for continuous compliance. |
11/17/2017
| Implemented |
| 6400.111(c) | The fire extinguisher was located at the front door and not in the kitchen. | 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 fire extinguisher has been moved and placed in the kitchen. Providence Home Care Agency will ensure that 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). House Managers will be responsible to conduct every weekly inspection to ensure fire extinguishers are allocated in each location, and tags are up to date to prevent future occurrences. Quality Assurance Manager will have oversight of the groups for continuous compliance. |
11/17/2017
| Implemented |
| 6400.112(e) | The fire drill records did not have a sleep drill every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | A new sleep drill has been conducted. Providence Home Care Agency will ensure that a fire drill shall be held during sleeping hours at least every 6 months. House Managers and staff will be responsible. To prevent future occurrences, House Managers will conduct monthly checks of fire drill records to ensure continuous compliance. Attachment#6 |
12/16/2017
| Implemented |
| 6400.141(a) | Individual #1's physical examination dated 8/30/16 is more than a year old. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical exams for individual#1 was completed on 12/05/17. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual¿s records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams |
12/05/2017
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination dated 8/30/16 did not document a hearing and vision screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Physical exams for individual#1 was completed on 12/05/17 which includes vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual¿s records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's physical examination dated 8/30/16 did not document that a Tuberculin skin was completed. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Physical exams for individual#1 was completed on 12/05/17 which includes Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual's records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination dated 8/30/16 did not document if the individual was free of communicable disease. | 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. | Physical exams for individual#1 was completed on 12/05/17 which includes Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals.. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual¿s records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination dated 8/30/16 did not document an assessment of health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Physical exams for individual#1 was completed on 12/05/17 which includes n assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual's records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination dated 8/30/16 did not document physical limitations. | The physical examination shall include: Physical limitations of the individual. | Physical exams for individual#1 was completed on 12/05/17 which includes Physical limitations of the individual. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual's records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination dated 8/30/16 did not document allergies. | The physical examination shall include: Allergies or contraindicated medications. | Physical exams for individual#1 was completed on 12/05/17 which includes Allergies or contraindicated medications. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual's records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 8/30/16 did not document information pertinent to diagnoses in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physical exams for individual#1 was completed on 12/05/17 which includes Medical information pertinent to diagnosis and treatment in case of an emergency. Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual's records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination dated 8/30/16 did not document diet instructions. | The physical examination shall include:Special instructions for the individual's diet. | Physical exams for individual#1 was completed on 12/05/17 which includes special instructions for the individual's diet. . Programs Specialist will ensure proper documentation is easily accessible showing physical examinations 12 months prior to admission and annually thereafter. To prevent future occurrences the program specialist will be responsible to review individual's records on a weekly basis and communicate to team leaders and staff all changes. An annual tracking sheet has been created to keep track of physical exams. Attachment 5 |
12/05/2017
| Implemented |
| 6400.142(a) | Individual #1's last documented dental exam was on 12/9/15. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | individual#1 had a dental appointment on 08/16/17 and 11/13/17. His is next scheduled appointment is 01/17/18. Programs Specialist will ensure proper documentation is easily accessible showing dental examinations. Moving Programs Specialist will ensure that an individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. .To prevent future occurrences the program specialist will review individual's records on a weekly basis and communicate to team leaders, staff all changes and update records with reports. A tracking sheet has also been created to prevent future occurrences. Attachment#2 #3 |
08/16/2017
| Implemented |
| 6400.151(a) | Staff person #2 did not have a physical examination. | 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. | A new Physical exam for staff #2 was set for 12/18/2017 waiting for results whiles staff is currently suspended. Human Resource Personnel will ensure that a new hire is not staffed in an individual's home prior to completing a physical. Moving Forward, HR will utilize a pre-employment checklist to ensure that prospective employees have all required documentation including a physical examination within 12 months prior to employment and annually thereafter. Physicals 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. |
12/18/2017
| Implemented |