| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-inspection was not dated. | 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.
| The agency will complete and date the self-assessment of each home for which we operate serving eight or fewer individuals, within the 3 to 6 month timeframe prior to the expiration date of our agency certificate of compliance. Moving forward, the agency will document and track the expiration date of our certificate of compliance so that future self-assessments can be completed and dated within the allotted time frame to stay in compliance with Chapter 6400.15(a). |
05/22/2017
| Implemented |
| 6400.21(a) | Staff #1 was hired on 11/6/16 and did not have a criminal background check completed. Staff #2 was hired on 9/5/16 and did not have a criminal background check until 9/29/16. Staff #3 was hired on 9/12/16 and did not have a criminal background check until 9/30/16. Staff #5 was hired on 9/7/16 and did not have a criminal background check until 9/21/16. Staff #7 was hired on 9/4/16 and did not have a criminal background check until 9/21/16. | 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.
| Months prior to the agency receiving their first individual, a number of employees had previously turned in their initial Criminal Background Check. Once the agency open with its first individual, those employees had to resubmit their criminal background checks, which ended up being dated after their date of hire. Moving forward, all new employees criminal background checks will be completed prior to their date of hire. |
05/22/2017
| Implemented |
| 6400.33(e) | There was a video camera in the living room of the home which recorded both audio and video. | An individual has the right to privacy in bedrooms, bathrooms and during personal care. | On 3/16/17, the video camera was removed to be in compliance with Chapter 6400.33(e). Moving forward, cameras will not be permitted to record audio and or video in any of our residential homes. |
05/22/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's annual physical dated 3/15/17 did not indicate if a tuberculin test was completed. | 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. | On 3/15/17, the individual received a PPD shot in the right arm (intradermal). On 3/17/17, the individual returned to PCP to have site read. Results was normal. |
05/22/2017
| Implemented |
| 6400.141(c)(10) | Individual #1's annual physical dated 3/15/17 did not indicate whether or not they were free from communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | On 3/17/17, the annual physical was returned to PCP to update whether or not the individual was free from communicable disease. The PCP checked off the yes box on the physical form. |
05/22/2017
| Implemented |
| 6400.142(a) | Individual #1 did not have a dental exam in their record. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | A appointment was scheduled for the individual. On 4/5/17, the individual was seen by Dr. Jill Bresler of Special Touch. He had an initial exam with x-rays. A follow-up appointment is scheduled for 10/11/17 at 11:45am. All future appointments will be scheduled at the end of each visit. |
05/22/2017
| Implemented |
| 6400.142(f) | Individual #1 did not have a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | A appointment was made for the individual to go to the dentist on 4/5/17. After being seen by the Dr. Jill Bresler, a written plan for dental hygiene was put into place which consist of the individuals current skill level for dental hygiene, recommendations and daily plan to achieve good dental hygiene. Moving forward, the dental hygiene plan will be updated as needed. |
05/22/2017
| Implemented |
| 6400.151(c)(2) | Staff #4 was hired on 1/28/17 and did not have a tuberculin test completed. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | On 3/17/17 staff #4 brought in a copy of his tuberculin test that was given on 8/30/16 in (LFA) and was read on 9/2/16. Results of completed tuberculin test was negative. Moving forward, our agency will make sure that all parts of the physical examination form including the tuberculin test is completed prior to the staff start date. |
05/22/2017
| Implemented |
| 6400.163(c) | Individual #1 is currently prescribed pyschotropic medications and has not had any 3 month medication reviews. | 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. | A appointment was scheduled with a licensed physician for a 3 month psychotropic medication review. The review was completed by Dr. Yamdama from COMHAR on 5/2/2017 at 2pm. Moving forward, all appointments will be scheduled ahead of time at the end of each visit for the following review. |
05/22/2017
| Implemented |
| 6400.181(a) | Individual #1 did not have an assessment in his record. | 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. | The Program Specialist will complete and back date the initial assessment to reflect 60 calendar days after admission to the residential home to be in compliance with Chapter 6400.181(a). The assessment will include an assessment of adaptive behavior and level of skills which was completed 6 months prior to admission. Moving forward, the Program specialist will complete all initial and annual assessments within 7 days of the date the assessment should be completed. (The date of the assessment will be the date it is conducted. No back dating will occur. Next annual assessment will be in line with the assessment from this one. ) |
05/22/2017
| Implemented |
| 6400.186(a) | Individual #1's record did not contain 90 day ISP reviews for the ISP dated 12/6/16. | 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 will complete and back date the 90 day ISP reviews to be in compliance with the residential home licensed under Chapter 6400.186(a). Moving forward, the Program Specialist will complete all reviews within 7 days of the review date. (Moving forward items will not be back dated. New reviews will be completed in-line with the current annual ISP) |
05/22/2017
| Implemented |