| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water in the shower/tub measured at 130.1*F. (Corrected) | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Commonwealth Supportive Services issued a work order to correct this issue. The maintenance man has installed a mixing valve into the faucet of the bathtub to adjust the water temperature to 110 degrees permanently. Please see work order invoice attached. |
08/23/2022
| Implemented |
| 6400.104 | Two fire department notices were provided, one to Yeadon's fire department and another to Darby's, with both letters also referencing Collingdale in the concluding paragraph. Neither letter included the addresses at which individuals with disabilities live nor specifics about where their bedrooms are located in the property. | 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.
| The Provider has modified the letters to the Fire Departments to the respective Boroughs for each home indicating the layout of the home specifically, the location for the individuals bedrooms residing in each. particular home. |
11/07/2022
| Implemented |
| 6400.110(a) | There was no operable automatic smoke detector located in the basement. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The Provider issued a work order to our maintenance man to install a smoke detector in the basement of this home. The smoke detector was installed 10/28/22 Please see work order invoice attached. |
10/28/2022
| Implemented |
| 6400.111(a) | There was no operable 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. | The Provider issued a worker order to install a new operable fire Extinguisher in the basement. The new operable fire extinguisher was installed in the basement on 9/2/22 Please see worker order invoice attached. |
09/02/2022
| Implemented |
| 6400.141(c)(6) | Individual #2 does not have a current TB test. The physical provided, dated 8/8/22, did not contain a record of a TB test; that section of the form was blank. The immunization record provided shows their last TB test was over two years ago, dated 1/8/20, and does not report the results. | 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. | Individual # 1 had his TB test done 11/8/22 Please find document attached. |
11/08/2022
| Implemented |
| 6400.141(c)(14) | The "Medical information pertinent to diagnosis in case of emergency" field was blank on Individual #2 8/8/22 physical. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist in collaboration with the Residential Mgr will ensure that the individual Physical is completed in its entirety form by the PCP annually to remain in compliance with the regulation. |
11/07/2022
| Implemented |
| 6400.144 | Individual #2 is a diabetic, his blood sugar is not being monitored or recorded. On the MAR staff initials that the individual's numbers are monitored at 8am and 8pm. The log and the diabetic meter are not being recorded and at times not even utilized. | 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.
| The Provider had a meeting with the Agency Nurse about the importance of adhering to individual medical prescription and documentation on August 23 2022 The Provider contacted a Certified Diabetic Trainer to retrain Commonwealth's staff on Insulin Administration and accurate documentation to ensure individual # 2 health, safety and wellbeing at all times, and to be compliant with the regulation. The training is in progress. |
08/23/2022
| Implemented |
| 6400.181(a) | Greater than one year elapsed between Individual #2 two most recent annual assessments, dated 7/30/20 and 9/20/21. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Moving forward, The Program Specialist will ensure that individual #2 annual assessments will be completed in a timely manner by the Individual's Annual Review Update to be in compliance with the regulation. |
11/07/2022
| Implemented |
| 6400.165(a) | Medication TYLONOL 650mg was in ind.#2 medication box and not prescribed by an authorized prescriber. No physician label was in the medication. | A prescription medication shall be prescribed in writing by an authorized prescriber. | The C.E.O. counseld Nurse to only maintain and administer prescribed medication only for Individual # 2. The nurse has removed Medication TYLENOL 650mg from individual # 2 medication box. |
08/23/2022
| Implemented |
| 6400.165(b) | Medication ACETAMINOPHEN 500mg is listed on the MAR and not present on site at time of inspection. Medication is not being kept current. | A prescription order shall be kept current. | This is an oversight by the Pharmacy. There has been no current prescription for Medication ACETAMINOPHEN 500MG. The C.E.O. counseled and reinforced with the Nurse to always make sure THE MAR is current at all times. |
11/07/2022
| Implemented |