| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #1 was hired on 8/9/2019, and Staff #1's criminal history check was not completed until 8/15/19. Staff #1 did not have a criminal history check completed within five days of hire. | 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.
| New ADP workforce Now contract will keep track of all criminal histories, physicals, and TB tests to ensure compliance with regulations. |
01/01/2023
| Implemented |
| 6400.112(c) | The fire drill completed on 6/21/23 did not include an evacuation time. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | SOP is being developed for Team Leads & Program managers regarding Fire drill forms and administrative review requirements (Completed 7/31/23)
Training on the Fire Drill form itself, SOP, and the administrative review process will be completed by 8/15/23.
|
08/15/2023
| Implemented |
| 6400.141(c)(6) | Individual #1's physical exam dated 4/4/23 (form indicated that exam took place on 1/5/23 and the form was sent to the physician to be completed on 4/4/23) did not include a tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | 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. | Intake physicals will be reviewed in a Team meeting prior to admission beginning 8/1/23 and ongoing. Incomplete physicals will not be admitted to the program until it is completed, no exceptions. |
08/01/2023
| 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. | Client services called all dentists on record and received recommendations (8/1/23) |
08/15/2023
| Implemented |
| 6400.181(e)(6) | Individual #1's initial assessment dated 4/26/23 did not assess the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Poison Safety question was added retroactively to all 2022/2023 Annual Assessments. |
07/24/2023
| Implemented |
| 6400.165(c) | Medications are not administered as prescribed. Individual #1 is prescribed Azelastine 0.1% (137mcg) spray. This medication is prescribed for seasonal allergies. This medication was filled on May 4, 2023. Inhale 1-2 sprays in each nostril twice daily directed. The medication bottle contained 200 metered sprays. At the time of the inspection the bottle contained more than half a bottle in the home. The medication is documented as administered as prescribed on the Medication Administration Record. | A prescription medication shall be administered as prescribed. | Individuals who are capable to self-administration of topical and nasal sprays will be evaluated for self-administration beginning 8/31/23 and ongoing. HCQU will review the correct usage of topicals, drops, and sprays in the training on 8/16/23. This training will be requested Annually from the HCQU. |
08/31/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. These medications were reviewed by a licensed physician on 4/18/23, 5/16/23, and 6/20/23 the form used did not include the necessary dosage of medications. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Medication lists will be attached to all psych notes for physician review and available when viewed in the scanned BOX paperwork (7/19/23 and ongoing)
Medical note updated to reflect Psychiatric med review of medications and the symptoms requiring ongoing treatment. |
07/21/2023
| Implemented |