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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was most recently inspected and cleaned in September 2020. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Immediate Action: NFHCS have received approval ( From the Management company) to have our own contractor, complete the annual inspection of all of our Apartments. We have notified our local professional contractor to conduct an Inspection and Cleaning of the furnace(s). The inspection has been scheduled for Nov 2,2021 at approximately 8:30AM. Copy of the inspection report and confirmation will be submitted and kept. |
11/29/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent physical examination, completed 10/11/2021, did not include medical information pertinent to diagnosis and treatment in case of an emergency. Separate documentation with medical information was provided to the Department; however, compliance could not be measured since the physician had not dated or signed the document. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Immediate Action: To ensure the previous medical information pertinent to diagnosis, had been reviewed. NFHCS has resubmitted the original addendum form for review and signature for Individual #1 . In addition, NFHCS has conducted an audit of all of our Residential Individuals original addendum. And has sent them to their MD, who completed the physical for acknowledgement and signatures. |
11/29/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.11 | Per 55 Pa. Code Chapter 20.21(b), "The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P.S. § § 1001---1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued. Not Forgotten Homes, Inc failed to submit an application for licensure of the home. Moreover, Not Forgotten Homes, Inc admitted Individual #1, who requires on average more than 30 hours of support per week, to the home on May 15, 2020 without the Department's approval and a valid Certificate of Compliance. | The requirements specified in Chapter 20 (relating to licensure or approval of
facilities and agencies) shall be met. | Individual/ Staff : Individual #1
Regulation # 6400.11 Chapter 20.
Immediate actions taken: Once NFHCS was notified, by the AE that the request to move Individual #1 from Residential Habilitation to IHCS was denied.( After the ISP team and Individual #1 had agreed on move) We immediately started on the licensing process. All documentation including corresponding emails with the SC, and AE was submitted to licensing during/ and after inspection. ( Submitted)
Administration Training: Enclosed is the Administration Training agenda, with signature page ( Enclosed)
Plan to Correct and prevent a reoccurrence/ similar violation in the future:
Going forward: NFHCS will receive Department approval ( Licensing) before making any relocation changes within our Residential Program. ( eg.. Licensing the home, getting approvals in writing, and corresponding with Licensing)
Person(s) Responsible:
¿ PS-
Date to be Corrected:
Corrected: August 27, 2020
[Prior to admission, the CEO shall ensure the licensing process is completed and the certificate of compliance is updated and accurately reflects the licensed community living homes. (DPOC by AES,HSLS on 9/2/20)] |
08/27/2020
| Not Implemented |
| 6400.141(c)(3) | The physical examination completed 6/25/2020 for Individual #1 that the last Tetanus, Diphtheria, and Pertussis immunization was completed 2009 and the next immunization was completed 8/5/2020. The recommendation by the United States Public Health Service is for the immunizations to be completed every 10 years. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual/ Staff : Individual #1
Regulation # 6400.141 ( c) (3)
Immediate actions taken: On August 5, during our inspection. Individual #1 received his TDAP booster. ( Enclosed is a copy of the of the booster)
Administration Training: Enclosed is the Administration Training agenda, with signature page ( Enclosed)
Plan to Correct and prevent a reoccurrence/ similar violation in the future:
Our Nurse has developed a checklist ( Enclosed) and updated his immunization record ( Enclosed) On August 17 & 18 our nurse conducted an audit of all residents, Immunization records. ( using the immunization tracker enclosed) All Residential Individuals Immunizations trackers ( Including) CDC Immunizations, will now be stored on NF Company Server ( Enclosed) Quarterly for 1 year, Our AED ( Assistant Executive Director) will complete an audit of all residential Physicals on the server. Copy of her reviews, findings and any POC will be kept.
Person(s) Responsible:
( Nurse Coordinator)
Asst Executive Director)
Date to be Corrected:
Corrected: August 27, 2020 |
08/27/2020
| Implemented |
| 6400.141(c)(4) | The physical examination, completed 6/25/2020 did not include a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual/ Staff : Individual #1
Regulation # 6400.141 ( c) (4)
Immediate actions taken: The vision exam was completed, ( Enclosed) and submitted during Licensing. Enclosed is the email confirmation for the requested documents, sent during our inspection on August 5.20 @9:37AM. The hearing exam was scheduled for June 2020. But due to Covid- 19. The Audiology office isn¿t seeing any group home patients until after Covid. Enclosed is a note from the Audiologist.
Administration Training: Enclosed is the Administration Training agenda, with signature page ( Enclosed)
Plan to Correct and prevent a reoccurrence/ similar violation in the future:
Our Nurse has developed a checklist ( Enclosed) Due to Covid-19, we couldn¿t obtain an audiology appointment. An audit of all individuals Physicals will be conducted, and completed by September 5th2020 , by NF Nurse Coordinator. A copy of her findings will be kept. All Residential Individuals Annual Physicals ( Including) Hearing and Vision screenings will now be stored on NF Company Server ( Enclosed) Quarterly for 1 year, Our AED ( Assistant Executive Director) will complete an audit of all residential Physicals on the server. Copy of her reviews, findings and any POC will be kept.
Person(s) Responsible:
Nurse Coordinator)
Asst Executive Director)
Date to be Corrected:
Corrected: August 27, 2020 |
08/27/2020
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of schizophrenia, anxiety disorder and depression. As of 8/5/20, there is not documentation of a medication review by a licensed physician. | 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. | Individual/ Staff : Individual #1
Regulation # 6400.165 (g)
Immediate action taken: NFHCS has finally received, the multiple requested Psych Review.
( Enclosed)
Administration Training: Enclosed is the Administration Training agenda, with signature page
( Enclosed)
Plan to Correct and prevent a reoccurrence/ similar violation in the future:
Due to Covid- 19, and after multiple attempts, the MD would not sign the psych review form. Unless Individual #1
could be seen in person. The MD did review the psych medication and sent prescriptions to
pharmacy. * Enclosed is the Psych Review Form. Requested: Individual #1
next psych appointment is scheduled for Nov 2, 2020 @ 9:30 Am ( Enclosed is a copy of his appointment Reminder)
Person(s) Responsible:
Nurse Coordinator)
Asst Executive Director)
Date to be Corrected:
Corrected: August 27, 2020 |
08/27/2020
| Implemented |
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