| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no documentation of a completed self-assessment 3-6 months prior to the expiration of the agency's certificate of compliance. | 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.
| Going forward Keystone Center For Family Development KCFFD will have a completed self assessment done 3-6 months prior to the expiration of our agency certificate of compliance, KCFFD has now hired the services of a new Compliance Officer by name Josie Wiley, going forward the CFO Sunday Nwegbo and Compliance officer Josie Wiley will be responsible for the completion of self assessment' |
06/22/2016
| Implemented |
| 6400.22(d)(1) | There was no documentation of an up-to-date financial record for funds received on behalf of individual #2. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | KCFFD has turned over all individual #2 finances to Advocacy Alliance to manage all individual #2 funds, receive Social Security benefits, disbursements, reconciliations of accounts and records keeping. [The program director or designee will review all client financial records to ensure that there is an up to date financial and proper record for all, within 30 days of receipt of this plan of correction. SW 1/4/17] |
06/16/2016
| Implemented |
| 6400.22(d)(2) | There was no documentation of an up-to-date financial record for funds disbursed to or for Individual #2. | (2) Disbursements made to or for the individual.
| KCFFD has turned over all individual #2 finances to Advocacy Alliance to manage all individual #2 funds, receive Social Security benefits, disbursements, reconciliations of accounts and records keeping, individual #2 funds has been turned over to Advocacy. [The program director or designee will review all client financial records to ensure that there is an up to date financial and proper record for all, within 30 days of receipt of this plan of correction. SW 1/4/17] |
06/16/2016
| Implemented |
| 6400.22(e)(1) | There was no documentation of a separate financial resources including the date and amount of deposit or withdrawal for individual #2. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | KCFFD has turned over all individual #2 finances to Advocacy Alliance to manage all individual #2 funds, receive Social Security benefits, disbursements, reconciliations of accounts and records keeping. [The provider will conduct an audit of financial records for all individuals served in residential setting, within 30 days of receipt of this plan of correction. SW 1.5.17]
Individual #2 accounts with KCFFD is closed and his remaining funds was turned over to Advocacy Alliance to open a new for individual #2, going forward Advocacy Alliance will deposit his funds and mange all his financials. |
06/16/2016
| Implemented |
| 6400.22(e)(3) | Individual # 1¿s financial record documented 17 purchases exceeding $15.00 from 05/18/2016 to 10/28/15 and there were no receipts for those transactions. | 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. | During inspection some receipts for her purchases was misfiled totaling two hundred and sixty three dollars and eight cents, we refunded this money to individual #1, a check for two hundred and sixty three dollars and eight cents was issued to her financial management firm Advocacy Alliance on 6/10/2016, going forward Advocacy Alliance will be responsible for all individual #1 finances, disbursements, financial records, social security benefits and reconciliation of accounts. |
06/10/2016
| Implemented |
| 6400.22(f) | $150.00 was being deposited into Individual #2's bank account to prevent monthly bank charges and the agency would withdraw the money thereafter. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | KCFFD has turned over all individual #2 finances to Advocacy Alliance to manage all individual #2 funds, receive Social Security benefits, disbursements, reconciliations of accounts and records keeping, individual #2 funds has been turned over to Advocacy,
Going forward Individual #2 account with KCFFD is now closed, all finances are now being managed by advocacy alliance |
06/16/2016
| Implemented |
| 6400.62(a) | Source antibacterial hand soap that says seek medical attention if ingested was left unlocked in the bathroom on the second floor. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 4/15/2016, KCFFD conducted a mandatory staffs training, all staffs were retrained on the handling of poisonous materials in our homes, all staffs was retrained and informed that all poisonous materials must be kept and locked and made inaccessible to individuals, going forward the CFO, Sunday M Nwegbo will ensure strict adherence to the 6400.62(a) |
04/15/2016
| Implemented |
| 6400.62(a) | Source antibacterial hand soap that says seek medical attention if ingested was left unlocked in the bathroom on the second floor. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 4/15/2016, KCFFD conducted a mandatory staffs training, all staffs were retrained on the handling of poisonous materials in our homes, all staffs was retrained and informed that all poisonous materials must be kept and locked and made inaccessible to individuals, going forward the CFO, Sunday M Nwegbo will ensure strict adherence to the 6400.62(a) |
04/15/2016
| Implemented |
| 6400.73(a) | There are three steps leading to and from the front entrance of the home and was no hand rails. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | KCFFD HIRED A LICENCED CONTRACTOR, A WELL-SECURED HAND RAIL LEADING TO ALL STEPS WAS INSTALLED ON 3/29/2016. [Maintenance staff will conduct an inspection of the physical sites for all residential locations, starting within 30 days of receipt of this plan of correction, to ensure that the homes are free from hazards. SW 1.5.17] |
03/29/2016
| Implemented |
| 6400.76(a) | The door handle/knobs was missing on the right closet door in Individual # 1's bedroom.
The side boards on the bed in individual #2's bedroom were loose and detached from the head board .
| Furniture and equipment shall be nonhazardous, clean and sturdy. | A certified maintenance contractor was hired, he replaced the missing knob on the right closet.
The contractor fixed the side boards on the bed in individual #2's bedroom, loose and detached headboard was reattached, the bed was fixed.[The maintenance staff or designee will conduct monthly physical site inspections of all residential homes to ensure that the homes are free of hazards, starting within 30 days of receipt of this plan of correction. SW 1.5.17] |
04/05/2016
| Implemented |
| 6400.81(k)(2) | There was no solid foundation for the mattress on individual #2's bed. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | On 5/27/2016, a brand new bed and mattress was bought and installed inside individual #2's bedroom, his old bed and mattress was replaced with a new bed and mattress. [The direct care staff will check mattresses monthly for all individuals residing in residential homes, starting within 30 days of receipt of this plan of correction and replace any mattresses in disrepair. SW 1.5.17]
25- |
05/27/2016
| Implemented |
| 6400.112(a) | Per Interview, staff were being notified prior to conducting the monthly fire drills. | An unannounced fire drill shall be held at least once a month. | On 4/15/2016 a mandatory staff meeting was held, all staffs conducting fire drill are prohibited from announcing the fire drill before conducting the Fire drill.
Going forward all fire drills must be unannounced effective 4/15/2016. |
04/15/2016
| Implemented |
| 6400.141(a) | Individual #3's date of admission was 5/16/15 and a physical examiniation was not completed prior to admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | initial Physical was completed prior to admission on 3/12/2015, but it was misfiled and was not available during inspections, KCFFD completed a new physical on individual #3 on 2/16/16, going forward prior year and current year physicals will be kept on file . KCFFD CEO will file all documentations. |
03/29/2016
| Implemented |
| 6400.151(a) | Per interviews, the Chief Executive Officer of the company has direct contact with the individuals and does not have a current physical exam. | 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. | On 07/11/2013, the Chief Executive Officer of KCFFD had a completed physical examination completed by her doctor, she also completed another second physical examination on 10/15/2015, during our just concluded inspections on we thought that it's not necessary to retain the old physical exam done on 7/11/2013 since she has her most current physical exam completed on 10/15/2015. going forward all physical exams will be kept on file during inspections, the CFO Sunday Nwegbo will ensure compliance |
06/22/2016
| Implemented |
| 6400.161(a) | Two capsules of Gabapentin were found loose in the medication box. | Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or weekly dispensing containers. | On 3/30/2016, we meet with representatives of our supply pharmacy Four Star Pharmacy, we discussed ways to ensure that all medications supplied to Keystone Center for Family Development met the standard 6400 regulations .161(a), as of 3/30/2016 we received a new packaging of blister packs of medications that are properly secured in their original containers.
Going forward this problems is henceforth resolved, and Keystone supervisor will monitor the process. |
03/30/2016
| Implemented |
| 6400.163(c) | Indivdiual #2's previosu psychological revew was 10/29/15 and the most recent psychological review was on 3/19/16. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Next 90 days that was completed on 05/10/2016, Going forward KCFFD nurse will be responsible for medication 90 day reviews, the next scheduled appointment is 7/19/2016. [The nurse will review all 90 day reviews to ensure that they are completed timely, starting within 30 days of receipt of this plan of correction. SW 1.5.07] |
05/10/2016
| Implemented |
| 6400.183(4) | Indidividual #1 receives 1:1 supervision and did not have a fading plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | On 3/30/16 meeting with our CFO, CEO support staffs and our Program Specialist , it was agreed that all future assessments for individuals must includes an expected outcome which requires the achievement of a higher level of independence and methods used to determine progress towards the expected outcome.
A procedure is now in place to ensure full compliance going forward. |
03/30/2016
| Implemented |
| 6400.183(5) | Individual #1 is currently prescribed Divalproex 500mg to be taken once a day for mood disorder, Divalproex 250 to be taken once a day for mood disorder, Clonazepam 2mg to take twice a day for anxiety and Haloperidol 5mg to be taken once a day for psychosis and did not have a social emotional and environmental plan (SEEP). | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | A meeting was held on 3/30/2016 with our Program specialist Ellen Jackson, it was resolved that going forward all assessments must include a protocol to address the social and emotional and environmental plan (SEEP), implementation has now been put in place going forward. [A review of all individual medication administration records will be conducted to ensure that a SEEP is completed, within 30 days of receipt of this plan of correction. SW 1.5.17] |
03/30/2016
| Implemented |
| 6400.186(c)(1) | Indivdiual #3's monthly documentation for December 2015 and January 2016 was not compelted. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | February, March, and April monthly documentations part of 6400 reg 186(c)(1), going forward the program specialist is the responsible completing all monthly documentations, KCFFD management staffs, CEO, CFO met with the program specialist on 4/8/2016 and agreed to complete all monthly documentations in a timely manner. [The Program Director will conduct periodic reviews of monthlies to ensure they capture an accurate review of the individuals progress and growth, starting within 30 days of receipt of this plan of correction. SW 1.5.17] |
05/05/2016
| Implemented |
| 6400.199(e) | Individual #3 was prescribed Ativan from 9/1/15 to 3/28/16. The medication was administered twice a day every day and was prescribed as needed | A Pro Re Nata (PRN) order for controlling acute, episodic behavior is prohibited.
| On 3/30/2016, Keystone Center For Family Development CFO met with the prescribing doctor Dr. Oyefule and Ms Leah Adewale who is the Chief Pharmacist of our pharmacy supply company Four Star Pharmacy, we discussed ways to avoid such mistakes in the future, the prescribing doctor Dr. Oyefule re-wrote the script to make it easier to understood, we received advise from both the Pharmacist and doctors, on 4/15/16, we retrained all our staffs on how avoid such errors in the future, training was conducted by a certified med trainer Ellen Jackson, going forward agency supervisor will monitor the process. |
04/15/2016
| Implemented |
| 6400.213(9) | Individual #3's record did not include a current copy of the Individual's Individual Support Plan (ISP). | Each individual's record must include the following information: A copy of the current ISP. | On 3/31/2016 during scheduled monthly support coordination's visit, we discussed with Carissa Smith SC for individual #3, we informed her that we cannot access copies of ISP in HCSIS, she stated that there was a glitch in HCSIS because SC did not include Keystone Center for Family Development KCFFD to receive a copy of the most current ISP, the support coordinator was able to resolve the Glitch, KCFFD received a copy ISP on 3/31/2016, the issues that prevented KCFFD from accessing copies of ISP in HCSIS was resolved on 3/31/2016, going forward the CFO of KCFFD Sunday Nwegbo will be responsible for resolving all technical issues with HCSIS system |
03/31/2016
| Implemented |
| Article X.1007 | Keystone Center for Family Development is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 was hired on 9/12/15; the criminal history check was requested on 10/14/15.Staff #2 was hired on 1/11/16; the criminal record was requested on 2/26/16. Staff #3 was hired on 8/1/14; the criminal record was requested on 10/29/15.
| When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Going forward Keystone Center For Family Development will ensure that all newly hired employees must pass state criminal background check before they are hired to work , KCFFD will retain record's on file for all employees, the CFO Sunday M Nwegbo will be responsible and ensure compliance with 55 PA Code Chapter Article X.1007 by reviewing all new hire documents within five days of hire. |
03/29/2016
| Implemented |