| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | (Repeated Violation -- 9/20/22) Individual #1's April and May 2023 financial ledgers indicates on 4/30/23, Individual #1 had $225.78 and on 5/1/23, they had $225.87. This $.09 difference continued through at least 7/31/23. | (2) Disbursements made to or for the individual.
| 8/31/23 - The math error for Individual # 1's financial ledger (of $0.09) was corrected by the house supervisor and subsequent financial ledgers were adjusted. (attachment # 14a,b,c,d) (5/1/23-7/31/23) |
09/11/2023
| Implemented |
| 6400.77(b) | At the time of the 8/31/23 inspection, the thermometer was not present in the first aid kit. | 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. | 9/1/23 - The house supervisor placed a thermometer inside the first aid kit of the home. (attachment #15a) |
09/21/2023
| Implemented |
| 6400.111(f) | There is no documentation provided verifying the fire extinguishers in the home were inspected before 9/30/22. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The CEO of Apex Healthcare Services, LLC reviewed the company's bank statements to determine the dates for the fire extinguisher inspection for 2022 (attachment #1 & 2). however, the receipts were for multiple homes on one payment. The receipts are also for the date of payment not the date of inspection. The CEO also said that they paid in cash for some of the inspections and did not get a receipt. The plan of correction is maintaining compliance with this regulation from this point forward by retaining actual receipts as well as keeping a Fire Extinguisher inspection Compliance Tracker. This will be kept in the Fire Safety Binder of the home. (attachment # 6) receipt. |
09/21/2023
| Implemented |
| 6400.144 | Individual #1 had a colonoscopy on 5/11/23, with prep completed on 5/10/23. Individual #1's Metformin was to be held both days, however, the Medication Administration Records indicate that the medication was administered to Individual #1 on 5/10/23. | 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.
| 9/21/23 - All staff will be re-trained on the importance of following doctor's instructions and what is required for an order to hold a medication (attachment #7). Documentation will be sent after the completion of this training. |
09/21/2023
| Implemented |
| 6400.151(c)(3) | Staff person # 3- 2/17/23 physical examination does not include a signed statement regarding the staff person's communicable disease status. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | 9/13/23-The provider of Staff person #3's physical was contacted by Apex to request that the doctor check the box on the physical form that was left unchecked (even though the negative PPD result was included with the physical). The provider of the physical requested that Staff # 3 be present. Staff member #3 is on personal leave due to a death in the family. When they return to work, they will have until 9/30/23 to complete this request. This documentation will be sent, once it is completed. |
09/30/2023
| Implemented |
| 6400.181(e)(10) | Individual #1's 2/14/23 initial assessment did not include a lifetime medical history. It did include 3 of the individual's diagnoses, but not a complete history. | The assessment must include the following information: A lifetime medical history. | 9/1/23 - The Program Specialist added the Lifetime Medical History to the initial assessment.
(attachment # 18.1-6) |
09/11/2023
| Implemented |
| 6400.214(b) | (Repeated Violation -- 9/20/22) The most recent Individual Support Plan at the home for Individual #1 was dated 6/5/23. Individual #1 had a plan update completed on 8/17/23. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| 9/1/23 - The Program Specialist printed the most current version of individual # 1's ISP and placed it in the individual records. On 9/13/23, the Program Specialist printed another revision. (attachment # 20) |
09/01/2023
| Implemented |
| 6400.24 | Staff person #3 and staff person #5 both had criminal records discovered upon hire, however documentation was not kept in the staff's records that the following case-by-case reviews were completed before hire:
· The nature of the crime,
· Facts surrounding the conviction,
· Time elapsed since the conviction,
· The evidence of the individual's rehabilitation; and
· The nature and requirements of the job. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | 9/15/2023: Apex reviewed the nature of the crimes on staff #3 and #5 and documented the nature, facts, time elapsed, rehabilitation, and job requirements (attachment # 22a &22b). |
09/11/2023
| Implemented |
| 6400.46(c) | Staff person #2 was hired on 4/25/23. This staff person did not have training on general first aid before working with individuals.
Staff person # 3 was hired on 2/20/23. This staff person did not have training on general first aid before working with individuals. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Staff person #2 who was hired on 4/25/23 completed CPR and First Aid training on 6/5/23.
Staff member # 3 who was hired on 2/20/23 completed CPR and First Aid Training on 4/18/23.
9/1/23 - The Director of Community Homes added First Aid Basics to the Orientation Checklist.
(attachment # 23) |
09/11/2023
| Implemented |
| 6400.165(b) | Individual #1 was prescribed Trazodone 50mg on 3/29/23. This medication was not administered to Individual #1 until 4/4/23. This medication was then increased to 100mg on 5/24/23. The 50mg dose was discontinued on 5/25/23, however, the new 100mg dose was not administered until 6/1/23. | A prescription order shall be kept current. | 9/1/23 - The Program Specialist and the House Supervisor were re-trained on obtaining new medications in a timely manner to ensure meds are given as soon as prescribed. They were also retrained on running an appointment, double checking scripts were sent from the medical professional to the pharmacy, ensuring pick up of medications, what to do if the pharmacy is closed and communication of new medications to DSP's in the home. (attachment #25 ) |
09/21/2023
| Implemented |
| 6400.165(c) | Individual #1 was taken to the emergency room on 5/20/23 for an anal fissure and external hemorrhoid. Individual #1 was prescribed PRN Protofoam and Docusate to help alleviate their current discomfort and help any future discomfort. Individual #1 was not administered either of these medications before 6/12/23. Individual #1 was taken to urgent care on 5/9/23 for a possible UTI and was prescribed Nystatin and Bactrim. These medications were not administered to Individual #1 on 5/11/23. | A prescription medication shall be administered as prescribed. | 9/1/23 - The Program Specialist and House Supervisor were re-trained on obtaining new medications in a timely manner to ensure meds are given as soon as prescribed. They were also trained on running appointments, checking scripts were sent from medical professional to the pharmacy, ensuring the pick up of medications in a timely manner, what to do if the pharmacy is closed, and communication to the DSP of the home. (attachment #25) |
09/21/2023
| Implemented |
| 6400.166(a)(4) | Individual #1 had to complete a colonoscopy prep on 5/10/23, which included administrations of Miralax. None of the medication administrations for the prep were documented on Individual #1's Medication Administration Record (MAR).
Individual #1 has the following PRN medications: Protofoam, Acetaminophen, and DG Anti-diarrheal. None of these medications are listed on the August 2023 MAR. Additionally, DG Anti-diarrheal is a standing OTC order and this order was not kept with the MAR.
Individual #1's PRN Acetaminophen was refilled on 7/20/23. At the time of the 8/31/23 inspection, 9 doses of the medication were documented as administered in August 2023, however, 17 doses have been administered. The other 8 administered doses were not recorded on the July or August 2023 MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | 9/1/23 - A PRN medication administrative record was created for all individuals by the program specialist. It was placed in their medication records. (attachment # 26a,b,c,d,e) |
09/21/2023
| Implemented |
| Article X.1007 | Staff person #2 was hired on 4/25/23. A Pennsylvania State Police Criminal Background check was not completed before this staff person's date of hire. | 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. | 9/13/23 - A PA State Criminal Check was completed. It is currently under review for control.
(attachment #21) |
09/13/2023
| Implemented |