| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Pennsylvania criminal history record checks were not submitted for Staff Person #1, date of hire 8/23/14, and Staff Person #2, date of hire 8/22/14. The criminal history record check for Staff Person #2, date of hire 1/10/14, was not completed until 4/11/14. | 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.
| All Criminal background checks are complete before hiring. Staff person #2 is the CEO's mother, the CEO did not complete the background check on time due to just opening the agency. All employees were hired after 1/10/14 had background checks completed before being hired. In 8/2014 the Agency moved an office and transferred files, some employees background checks were lost during the move. This was told to inspectors during licensing. [Immediately, all staff persons including staff person #1 and staff person #2 will have a criminal history check completed using the PA patch system. Immediately, all current staff members Criminal History Record Checks will be reviewed to ensure that they have been obtained through the PA Patch system and contain no prohibitive offenses in accordance with the Older Adult Protective Services Act and Act 13. Any staff persons found to have a criminal history containing prohibitive offenses per OAPSA will be terminated immediately. All administrative staff that plays a role in the hiring process will complete the Department of Aging Abuse and Criminal History Check Training by 12/15/13 which can be found at http://www.portal.state.pa.us/portal/server.pt/community/self_study_course/18031 . Documentation shall be kept. (CHG 1/20/15)] |
10/17/2014
| Not Implemented |
| 6400.23 | The home does not have a written grievance procedure for individuals, individual's families, advocates and staff persons that assure investigation and resolution of complaints. | The home shall have written grievance procedures for individuals, individual's families, advocates and staff persons, that assure investigation and resolution of complaints.
| A written grievance procedures for individuals, individual's families, advocates and staff persons, that assure investigation and resolution of complaints was written and implemented.[All staff and individuals will be trained on the procedures within 30 days upon receipt of the plan of correction. (CHG 1/20/15)] |
10/17/2014
| Implemented |
| 6400.31(a) | Individual #1, admitted on 1/10/14, was not informed of the individual rights until 1/13/14. | Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. | All future residents will be informed of their rights on the day of admission by the program specialist. [Immediately and annually thereafter, all individuals in all community homes will be informed of their rights. The CEO or designee will audit all individuals records to ensure that there are statements signed and dated by the individual, or the individual¿s parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, in each individual¿s record. Documentation shall be kept. (CHG 1/20/15)] |
10/17/2014
| Not Implemented |
| 6400.68(b) | The hot water temperature in the bathtub was 124.1 degrees Fahrenheit at 11:15 a.m. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water temperatures were adjusted and corrected during the inspection. The water temperature will be check frequently to ensure the proper temperature according to the regulation.[Immediately, the hot water temperature at all site locations will be turned down until the temperature reads at or below 120 degrees Fahrenheit. The CEO or designee will check the hot water temperature at all bathtubs and showers weekly at every community home and record the temperature on a log. If the temperature is found to be above 120 degrees Fahrenheit it will be turned down immediately. Documentation shall be kept. (CHG 1/20/15)] |
10/17/2014
| Not Implemented |
| 6400.103 | The emergency evacuation procedures do not specify the means of transportation and the emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The policy was updated to include the means of transportation and the location of the emergency shelter location. All staff are trained on the emergency evacuation procedure upon hire. [All staff will be educated on the policy within 30 days upon receipt of the plan of correction. (CHG 1/20/15)] |
10/17/2014
| Implemented |
| 6400.106 | There is no written documentation of the inspection and cleaning of the furnace. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The furnaces in all homes were inspected by a professional and receipt was submitted. QCL will continue to conduct inspections annually. |
10/17/2014
| Implemented |
| 6400.110(h) | There is no written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative. | There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative. | A written procedure was written and implemented on fire safety monitoring in the event the smoke detector or fire alarm is inoperable.[Immediately, a procedure will be written and implemented for fire safety monitoring in the event that the smoke detector or fire alarm are inoperable. All staff will be educated on the policy/procedures within 30 days of receipt of the plan of correction. Documentation shall be kept. (CHG 1/20/15)] |
10/17/2014
| Not Implemented |
| 6400.111(c) | A fire extinguisher was not located 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 was relocated to under the kitchen sink. the prior location was sketchy so they were removed in all apartments to under the sink.[All staff will be informed of the location of the fire extinguishers prior to working in the community homes. (CHG 1/20/15)] |
10/17/2014
| Implemented |
| 6400.145(1) | The home does not have a written emergency medical plan listing the hospital or source of health care that will be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Staff are trained upon hire of the hospital used in case of an emergency. The policy is the home for staff to reference. [All staff will be trained on the plan within days upon receipt of the plan of correction. (CHG 1/20/15)] |
10/17/2014
| Implemented |
| 6400.145(2) | The home does not have a written emergency medical plan listing the method of transportation to be used. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | THe Written emergency Plan was updated to include the method of transportation and is placed in a binder in the homes. [All staff will be trained on the plan within 30 days upon receipt of the plan of correction. (CHG 1/20/15)] |
10/17/2014
| Implemented |
| 6400.145(3) | The home does not have a written emergency medical plan lisintg an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | The Emergency medical plan was updated and placed in a binder in each individual home. The emergency staffing plan is also listed in the individuals ISP. [All staff will be trained on the plan within 30 days upon receipt of the plan of correction. (CHG 1/20/15)] |
10/17/2014
| Implemented |
| 6400.181(f) | Individual #1's assessment, completed 9/3/14, was not provided to the SC and plan team members at least 30 calendar days prior to the ISP meeting which is scheduled to be held on 10/9/14. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| THe Program Specialist did send the assessment on time however did not include a letter to the SC along with the assessment. The Program Specialist will send a written letter to the SC along with the assessments on the future. |
10/17/2014
| Implemented |
| 6400.186(a) | The quarterly reviews for Individual #1, admitted on 1/10/14, were completed on 4/1/14 and 8/11/14. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The program specialist has completed an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The Program Specialist corrected the review date typo to 7/11/2014. |
10/17/2014
| Implemented |
| 6400.192 | There is no written policy regarding restrictive procedures. | A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the home.
| Restricitve Procedure policy was written. Quality Community Living does not use any restrictive procedures throughout the agency. all staff are trained on the policy. |
10/16/2014
| Implemented |
| 6400.213(10)(iv) | Individual #1's record did not include a notice that plan team members may decline the ISP review documentation. | Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation. | Documentation was created for all team members excluding SCO's to decline the ISP review documentation. The documentation was implemented and will be given to all team members. The Program Specialist will present the document at all ISP meetings. |
10/17/2014
| Implemented |