| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | At the time of inspection, no Self-Assessments were completed.(Repeat Violation: 3/2/2016) | 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.
| Quality Life will ensure that the Self assessment is done in a timely manner by using Tabula Pro which will send a reminder to program specialist and/or designated person every 6 months prior to expiration date of the agency's certificate and the system will send another alert in 3 month letting the program specialist and the designated person that the self assessment needs to be completed and submitted. |
05/23/2017
| Implemented |
| 6400.18(b) | Quality Life Human Services' IM policy states medication omissions & errors are reportable incidents. Quality Life is not following this policy. Hospitalizations and ER visists are also reportable incidents. Through Staff interviews it was reported there have been several hospitalizations/ER visits for Individual #3 that have not been reported through EIM. | Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home.
| All staff hired by Quality Life will be retrained on incident management., reporting incidents on a timely manner. |
06/17/2017
| Implemented |
| 6400.21(a) | Staff #4 was hired on 4/8/2016. There was no Criminal History Check completed.(Repeat Violation: 3/2/2016) | 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.
| Staff #4 will have a criminal History check completed on 5/24/2017 and will use Tabular Pro to Alert Program Specialist , Supervisor and designated person when staff criminal History Check are due so they can be completed on a timely manner. |
05/24/2017
| Implemented |
| 6400.46(i) | Staff #4 has a certification card (2/9/16) for CPR only. At the time of inspection, there is no documentation or certificate of 1st Aid & Heimlich training for staff #4. At the time of inspection there was no documentation or certification of 1st Aid, CPR & Heimlich training for staff #5. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff # 4 has been trained in First Aid, CPR and the Heimlich maneuver since last inspection. Quality Life will ensure that all staff is trained as required by ODP. Q.L.H.S will use tabular pro to help Program Specialist and designated person manage our required training in a timely manner. |
05/23/2017
| Implemented |
| 6400.77(b) | The 1st Aid Kit in this residence had no thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Thermometer has been purchase and all first aid kit has a thermometer. |
04/12/2017
| Implemented |
| 6400.110(h) | There is no fire safety monitoring procedure in the event the smoke detector/fire alarm is inoperative in this residence. | There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative. | QLHS has created policy and procedure pertaining to operative alarm system and trained all tem members. Staff and individual has signed such plan and received training. |
04/12/2017
| Implemented |
| 6400.141(a) | Individual #3 was admitted on 11/26/2016 without a physical exam. As of the date of this inspection, she still has not had a physical examination.(Repeat Violation: 3/2/2016) | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #3 has been in and out of the hospital since she has been in Quality Life we have had a difficult time scheduling appointment due to her hospitalization. Quality Life will require that all individuals interested in moving into our residential home will be asked to have a physical examination completed and given to the program specialist and or designated person for review.
((Individual #3 will receive a physical examination - CH 6/12/17)) |
05/28/2017
| Implemented |
| 6400.141(c)(14) | This section was blank on Individual #2's physical exam. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | QLHS has designated person to ensure that all medical information is completed before leaving appointment. |
05/04/2017
| Implemented |
| 6400.144 | According to Individual #2's Psychiatric Progress Notes, his 9/7/16, 1/3/17 and 1/31/17 forms indicate he has not had his labs done as requested. The 1/3/17 form states that he "hasn't had labs done in 6 months which is concerning due to use of VPA & Lithium." Individual #3's MAR sheets state: "Check weight daily-Notify MD if weight increases or PT is retaining fluid." At the time of inspection, there was no documentation of her weight being checked. | 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.
| Individual #2 did have his labs done as requested by his psychiatric and the information was taken to ODP office. To ensure that all requested labs are completed in a timely manner all team leaders are responsible for going with the individual to all appointments and the supervisor will be responsible for making sure all documents are received. |
05/25/2017
| Implemented |
| 6400.151(a) | Staff #4 was hired on 4/8/2016. On the date of inspection, there was no documentation of her having an initial physical exam. Staff #5 had a physical exam on 2/6/2015. At the time of inspection, there was no documentation of him having a physical exam completed in 2/2017.(Repeat Violation: 3/2/2016) | 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. | Staff #4 and Staff #5 will have there Physicals done on Friday 5/26/17. To ensure that all physicals are completed before there start date. the program specialist and designated person will ensure that all required forms are received and documented on the new hire check list. |
05/29/2017
| Implemented |
| 6400.161(e) | On 2/16/17, Individual #2 was prescribed Scar Gel (BID): Apply to wound for 15 days. This medication was still in his med box on 3/23/2017. On 2/10/17, Individual #2 was prescribed Double Antibiotic Cream (TID): Apply to infected area for 7 days. This medication was still in his med box on 3/23/2017. Individual #2 was prescribed Bacitracin Zinc (BID) for wound care. It was discontinued by his doctor (date unknown). This medication was still in his med box on 3/23/2017. | Discontinued prescription medications shall be disposed of in a safe manner. | QLHS staff has been trained to monitor and dispose of all medication that was discontinued by the doctor. Policy and procedure has been review with all team members to ensure proper disposal of discontinued medication. |
04/12/2017
| Implemented |
| 6400.163(c) | Individual #2 had psychiatric medication reviews on 4/18/16, 5/18/16, 7/16/16, 8/9/16, 1/31/17, and 2/28/17. The time frame between 8/9/16 and 1/31/17 exceeds the 3 month requirement.(Repeat Violation: 3/2/2016) | 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. | to ensure that Individual #2 have all required Psychiatric medication review Quality Life will use a system called tabular pro that will alert staff when all required document and appointment are due. the Program Specialist and designated person will be responsible for keeping track of all appointments |
05/29/2017
| Implemented |
| 6400.164(b) | The following medications were not logged as administered for Individual #2: Lamictal(8AM), Zantac(7AM), and Senokot(8AM) on 12/1,12/2, and 12/6/16; Zantac(4PM) on 12/1 and 12/2/16; Senokot(8PM) on 12/6/16; Topomax(8AM) on 12/1/16; and Econazole Nitrate Cream(8AM) on 12/2/16 through 12/4/16, 12/6, and 12/18 and 12/19/16. The following medications were not logged as administered for Individual #3: Nystatin (8am) on 1/13/17, 1/14/17 and at 8pm on 1/14/17; Flonase (8am) 1/13/17; Minipress (8PM) on 1/26 & 1/27/17; Colace (BID) at 8am on 1/26-1/28/17 and at 8pm on 1/26-1/27/17; Lith Carb ER (BID) at 8am on 1/26-1/28/17 and at 8pm on 1/26, 1/27, 1/29-1/31/17; Cogentin (8am), Lexapro (8AM); Flonase (8am), Synthroid (8am) and Protonix (7am) on 1/26-1/28/17; Claritin (BID) at 8am on 1/26-1/28/17 and at 8pm on 1/26-1/27/17; Klonopin (BID) at 8am on 1/26-1/28/17 and at 8pm on 1/26, 1/27 and 1/31/17. Cymbalta(8AM) on 2/22 and 2/28/17; Fish Oil(8AM) on 2/26 and 2/28/17;Lamictal(8AM)on 2/2, 2/10, and 2/28/17;Alavert(8AM),Rexulti(8AM),Catapres(8AM), and Depakote ER(8AM)on 2/28/17; Depakote ER(8PM) and Felbatol(8PM)on 2/7/17, Felbatol(8AM)on 2/22 and 2/28/17; Zantac(7AM)on 2/8, 2/9, 2/22, and 2/28/17. Zantac(4PM) on 2/7/17;Senokot(8AM)from 2/25-2/28/17;Senokot(8PM) on 2/7 and 2/24/17;Topamax(8AM)on 2/22,2/23, and 2/28/17; Topamax(8pm)on 2/7/17 and Briviact(8AM & 8PM) on 2/23/17. (Repeat Violation 3/2/2016) | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | All staff and team leader of Individual #2 will double check Individual #2 and the supervisor will do weekly check and team leaders will do daily check to ensure all MAR s field out as medication are taken. |
05/25/2017
| Implemented |
| 6400.167(b) | The medication administration record for Individual #2 indicates Colace (8am & 8pm) was discontinued on 12/16/16. However, this medication was initialed as administered at 8am from 12/17/16 to 12/21/16. It was initialed as administered at 8pm from 12/16/16 to 12/19/2016. The record also indicated Decadron (8am) was discontinued on 12/16/16. It was initialed as administered from 12/17/16 to 12/21/16. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Quality Life Staff will be retrained in medication administration recording by our medication trainer to ensure that this violation does not happen again and the team leader and supervisor will do daily and weekly checks. |
06/08/2017
| Implemented |
| 6400.181(a) | Individual #2 was admitted on 8/24/2015. An assessment has not been completed. (Repeat Violation: 3/2/2016) | 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. | Individual #2 assessment was completed and submit to ODP. At the time of inspection Individual #2 SC had the assessment to make a copy. |
05/25/2017
| Implemented |
| 6400.186(a) | For the past year, 3 month ISP reviews have not been completed for Individual #2.(Repeat Violation: 3/2/2016) | 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. | Quality Life has created monthlies for Individual #2 and will complete monthlies. to ensure that the 3 month ISP review is completed on a timely manner the program specialist and designated person will use tabular pro to send alerts when the ISP review is due. |
06/05/2017
| Implemented |
| 6400.186(c)(1) | For the past year, monthly documentation of Individual #2's participation and progress during the prior 3 months toward his ISP outcomes hasn¿t been done.(Repeat Violation: 3/2/2016) | 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. | Quality Life Program Specialist and Supervisor has created Monthlies for Individual #2 since last inspection.
to ensure that this does not happen again Q.L.H.S will use a program called tabular pro to help program specialist and designated person keep track of all required documents. |
05/25/2017
| Implemented |
| 6400.213(1)(i) | Identifying marks for Individual #2 is not listed in his record. Religious Affiliation for Individual #3 is not listed in her record. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Identifying mark, religious has been updated on all necessary records. All QLHS employees has been trained to ensure that all records indicate all marks and religious. |
05/04/2017
| Implemented |