| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Over the counter medications and poisons were found unlocked in several areas around the apartment. Triple antibiotic ointment, Lysol spray, wound care spray, and a spray bottle of 91% isopropyl alcohol were found in an unlocked closet near the half bathroom. Comet cleaner was found in an unlocked cabinet beneath the sink in the half bathroom. Per their ISP, Individual 1 must be protected from poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The containers with poisonous substances were immediately removed from their unsecured locations and placed in a locked cabinet where ALL poisonous substances are usually kept. |
| Implemented |
| 6400.64(a) | Material consistent with dirt or grime was seen built up along the base of the interior of the dishwasher. | Clean and sanitary conditions shall be maintained in the home. | The dishwasher was cleaned of the dirt or grime immediately after the inspection was completed. |
08/12/2022
| Implemented |
| 6400.64(b) | Insects were seen crawling along the base of the interior of the dishwasher. | There may not be evidence of infestation of insects or rodents in the home. | The maintenance department of the apartment complex was informed of the crawling insects seen at the base of the dishwasher. Within that week the apartment was treated by exterminators for crawling insects. |
08/14/2022
| Implemented |
| 6400.142(g) | Individual 1's dental hygiene plan was not rewritten annually. The two most recent dental hygiene plans in the individual's file are dated 6/27/20 and 5/3/22. | A dental hygiene plan shall be rewritten at least annually. | Dental Hygiene Plan missing for 2021 has been written. |
12/31/2022
| Implemented |
| 6400.181(a) | Individual 1's assessments are not completed annually. Their 2/15/22 assessment indicates the last assessment update was written on 3/24/21, less than a year prior. Per that document, the update prior to that was dated 7/27/20, also less than a year prior. Assessments must capture a full year of information. | 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 last update of the Assessment was changed to show that it was one year after the previous update. All information for that period was included. |
02/02/2023
| Implemented |
| 6400.52(c)(1) | Staff Member 1' 2021,annual training did not cover the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | A) All required mandatory training was completed by 1/12/22 by staff who had not completed those trainings earlier for the training year, 2022. |
12/31/2022
| Implemented |
| 6400.52(c)(2) | Staff Member 1' 2021 annual training did not cover the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | All required mandatory training was completed by 1/12/22 by staff who had not completed those trainings earlier for the training year, 2022. |
12/31/2022
| Implemented |
| 6400.52(c)(3) | Staff Member 1' 2021 annual training did not cover individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | This staff member will comple the required training. |
12/31/2022
| Implemented |
| 6400.52(c)(4) | Staff Member 1' 2021 annual training did not cover recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | All required mandatory training was completed by 1/12/22 by staff who had not completed those trainings earlier for the training year, 2022. |
12/31/2022
| Implemented |
| 6400.52(c)(6) | Staff Member 1' 2021 annual training did not cover ISP plan implementation for any individuals they work with. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All required mandatory training was completed by 1/12/22 by staff who had not completed those trainings earlier for the training year, 2022. |
12/31/2022
| Implemented |
| 6400.165(g) | Individual 1's file does not contain documentation of quarterly medication management medical appointments. Documentation from the past year was requested, but only one visit's documentation was submitted, dated 6/7/22. The individual's lifetime medical document references 5 different medication management visits in 2022. | 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. | This is an error. Medical Reviews for all visits were submitted as requested at the time of inspection. These reviews will be resubmitted by email on 2/2/2023. |
02/02/2023
| Implemented |
| 6400.166(a)(13) | Individual 1's 1mg Risperidone administrations were not signed for in their MAR at 8PM on 8/11/22 nor 8AM on 8/12/22. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The staff who administered the medication on that day was reminded of the implications of forgetting to initial the MAR immediately after a medication has been administered. The staff completed this step of the medication by initialing the appropriate boxes on the MAR. |
02/02/2023
| Implemented |