| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual # 1's financial ledger had a balance of $100.61 on 8/24/2021. On 8/25/2021, $3.18 was spent at the Dollar Tree which gives a new ledger balance of $97.43 However, the ledger balance was incorrectly recorded as $97.44. | (2) Disbursements made to or for the individual.
| The math on the financial ledger was re-calculated for Individual #1. Individual #1's money was counted. The log shows that she has $0.01 more than is actually there. The August log was corrected immediately on 9/2/21. Attachment #14. All other individual's financial logs were audited by the Program Specialist and the Director of Community Homes to ensure correct documentation and balances. |
09/17/2021
| Implemented |
| 6400.111(a) | The office had an entrance to the attic via pull chord. There was a fire extinguisher in the office room on the wall, however there was not a fire extinguisher located in the actual attic itself, which is on another floor. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | On 9/9/21, a new fire extinguisher was purchased and placed in the attic of the home. Attachment #16 |
09/17/2021
| Implemented |
| 6400.141(c)(6) | Individual # 1 had a TB test completed on 7/21/2019 and not again until 8/30/2021, which was 39 days late. This also exceeds the 15-day grace period, which ended on 8/6/2021. | 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. | Apex uses a form to keep track of annual appointment dates. On 9/11/21, this form was revised to include the Tuberculin skin test. All Apex individual's annual appointment information will be transferred to the new form. On 9/11/21, Individual #1's new form was completed and is Attachment #18. |
09/30/2021
| Implemented |
| 6400.141(c)(13) | The most recent physical for individual # 1 dated 8/30/2021 did not contain information on any allergies or contraindicated medications. This section was left blank. | The physical examination shall include: Allergies or contraindicated medications. | On 9/13/21, the Program Specialist contacted the PCP for Individual #1 and requested that the blank space on the physical for allergies, be filled in with No Known Allergies. The newly completed form was received and is Attachment # 19. |
09/17/2021
| Implemented |
| 6400.166(a)(13) | At the time of the inspection, there were no staff initials documented on the medication administration record (MAR) for Individual # 1's 7am dose of medication called, "Venlafaxine HCL ER" 75mg Capsule for a dx of Depression on 8/26/2021.
It is unclear if the medication was not administered or if the staff person who administered the medication failed to initial the medication administration record (MAR) for that specific date and time.
At the time of the inspection, there were no notes documented that would explain the empty MAR box on this specific day/date nor related to this specific medication/ medication time.
The initials of the staff member who administered other medications on that specific date and time was staff #2 | 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. | On 9/3/21, the Program Specialist spoke with Staff #2 regarding the empty initial box on Individual #1's MAR for the 7 am dose of Venlafaxine HCL ER 75mg on 8/26/21. Staff #2 said that she gave Individual #1 all of her 7 am medications. The Program Specialist and the Director of Community Homes reviewed the blister packs for August and found that the pill was popped and Staff #2's initials were on the back of the blister pack for 8/26/21. Therefore, Staff #2 initialed the MAR for 8/26/21 for Individual #2's 7am Venlafaxine. Attachment #20. |
09/24/2021
| Implemented |
| 6400.181(f) | At the time of the inspection, the Program specialist for individual # 1 provided email verification that the most recent annual assessment dated 7/20/21 was emailed to individual # 1's SC on 8/20/2021, which was the day after the annual ISP meeting took place (8/19/2021). Thus, failing to give the 30 calendar days as required by this regulation | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | On 9/10/21, the Program Specialist was trained on the due dates for the Annual Assessment as well as all annual paperwork. Attachment #24. |
09/13/2021
| Implemented |
| 6400.182(c) | The Educational/vocational information section of individual # 1's most recent ISP, dated 5/12/2021 states that the individual still attends CIT vocational center. However, Individual #1 retired from CIT on 3/30/2021 due to the current progression of her Dementia Diagnosis. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | As the Acting Program Specialist, the Director of Community Homes, should have included Individual #1's retirement in the January-March quarterly. When the error was discovered through the inspection process, the current Program Specialist contacted Individual #1's Support Coordinator on 9/2/21, to ensure that the change will be reflected in the new ISP. |
09/24/2021
| Implemented |
| 6400.183(a)(3) | At the time of the inspection, there was no documentation that demonstrated a DSP was a part of individual #1's Individual Plan team. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | On 8/23/21, Director of Community Homes and the Program Specialist reviewed Individual #1's current ISP and revisions discussed at the recent annual ISP meeting with all staff from the home where individual #1 resides and all staff who are crossed trained from other homes. On 8/23/21, Director of Community Homes and the Program Specialist reviewed Individual #1's Health and Safety Implementation Plan with all staff from the home where individual #1 resides and all staff who are crossed trained from other homes. At the time of the review, all DSP's were invited to give input and clarify any information needed. While there was not a DSP present at the annual ISP meeting, they were given the opportunity to give input into Individual #1's plan. Attachment #26. |
09/13/2021
| Implemented |
| Article X.1007 | APEX is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Service Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #1 was hired on 5/17/2021 but the criminal background check was not completed until 5/19/2021. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | 9/10/21 - Apex will begin a new application process which requires the applicant to produce a current PA criminal history check to present with the application. If the applicant does not have a current PA criminal history check, one will be requested prior to hire. No prospective employees will be given a hire date or begin training until Apex receives a PA criminal history check that complies with 10225.502 and 10225.503. On 9/10/21, Apex Community Homes interviewed a new applicant. She did not have a PA criminal history check. Apex applied for a PA criminal history check on 9/13/21. APEX is awaiting the results. the Criminal check came back as "request under review for control". Attachment #21. When the criminal check come back and if the applicant complies with 10225.503, Apex will offer them a start date and begin their training. PA criminal history checks and start date for this applicant will be Attachment # 21a. It will be forwarded to the lead inspector when the results are received. |
09/30/2021
| Implemented |