Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(c) | The agency's self-assessment completed on 10/12/20 does not include a written summary of corrections. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Pa Code 6400.15 (c)
1. The agency self-assessment completed on 10/12/20 does not include a written summary of corrections for the identified violations. Corrections to violation were made on 11/6/2020. All violations will include a written summary of corrections shall be made and kept by the agency for at least 1 year by the agencys License Compliance Manager.
2. Other locations were found to have been in violation of this, violation was addressed with License Compliance Manager and corrected on 11/6/2020.
3. All staff will be trained on this regulation by CEO to ensure that all self-assessments remain in compliance with this regulation. All staff will be trained by 12/31/2020.
4. Self-Assessments will be reviewed on a yearly basis by License Compliance Manager and CEO.
ATTACHMENT #6 |
11/06/2020
| Implemented |
6400.141(c)(15) | Individual # 1's physical exam dated 07/28/20 does not include information on the Dietary needs of the individual. The space was left blank. | The physical examination shall include:Special instructions for the individual's diet. | Pa Code 6400.141 (c) (15)
1.Individual # 1's physical exam dated 07/28/20 does not include information on the Dietary needs of the individual. The space was left blank.
2. All other locations were incompliance with this regulation. This violation was addressed with Medical Coordinator and will be corrected by 11/16/2020.
3. All staff will be trained on this regulation by Medical Coordinator to ensure all physicals are properly documented and completed. All staff will be trained by 12/31/2020.
4. All physicals will be reviewed by Medical Coordinator on a yearly basis.
ATTACHMENT #7 |
11/16/2020
| Implemented |
6400.181(e)(7) | Individual # 1's assessment dated 10/29/20 does not include her ability to move away quickly from heat sources. The assessment reads that she can "stay away" from and "avoid" heat sources. | 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. | Pa Code 6400.181 (e) (7)
1. Individual # 1's assessment dated 10/29/20 does not include her ability to move away quickly from heat sources. The assessment reads that she can "stay away" from and "avoid" heat sources. Violation was corrected on 11/6/2020.
2. All other assessments were reviewed by the Program Specialist on 11/10/2020 and all others were found to be incompliance with this regulation.
3. The Vice President will review all assessments with Program Specialist on a yearly basis to ensure compliance.
4. Program Specialist was trained by Vice President on 11/9/2020 on regulation 6400.181 (e) (7) ensuring that all assessments read individuals ability to move away from heat sources.
ATTACHMENT #8 |
11/06/2020
| Implemented |
6400.217 | Individual # 1's record does not include any signed releases of information for her external treatment provider, Alternative Community Resource Program. | 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.
| Pa Code 6400.217
1. Individual # 1's record does not include any signed releases of information for her external treatment provider, Alternative Community Resource Program.
2. Other locations were found to have been in violation of this, violation was addressed with CEO and will be corrected by 12/31/2020.
3. All staff will be trained on this regulation by CEO to ensure all individuals have signed releases of information by 12/31/2020.
4. Individual releases will be reviewed on a yearly basis by License Compliance Manager and CEO.
ATTACHMENT # 9 |
12/31/2020
| Implemented |
6400.31(b) | Individual #1's individual rights notification form signed 09/08/20 does not include being informed of Regulation 32r which includes the right to have locks on doors. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Pa Code 6400.31 (b)
1. Individual #1's individual rights notification form signed 09/08/20 does not include being informed of Regulation 32r which includes the right to have locks on doors.
2. Other locations were found to have been in violation of this, violation was addressed with CEO and corrected on 11/9/2020. The CEO shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights yearly.
3. All staff will be trained on this regulation by CEO to ensure signed releases are completed on a yearly basis for all individuals. All staff will be trained by 12/31/2020.
4. Individual rights will be reviewed on a yearly basis by License Compliance Manager and CEO.
ATTACHMENT #10 |
11/09/2020
| Implemented |
6400.166(a)(11) | Individual # 1 is prescribed Clotrimazole Cre 1%. The reason for the medication is not listed on the MAR or the medication label | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Pa Code 6400.166 (a) (11)
1. Individual # 1 is prescribed Clotrimazole Cre 1%. The reason for the medication is not listed on the MAR or the medication label
2. All other MAR¿S were reviewed by Medical Administrator to ensure each medication has a Diagnosis; all other homes were found to be incompliance with this regulation.
3. All staff will be trained on this regulation by Medical Administrator to ensure all homes remain in compliance with this regulation. All staff will be trained by 12/31/2020. |
12/31/2020
| Implemented |