| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The following staff members did not have a Pennsylvania criminal background check on file within five days of employment:
- Staff #7
- Staff #8
- Staff #9 | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees 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. | Program Assistant notified CEO and Program Manager of missing files. Administrative Assistant performed PA background checks of staff 7,8, and 9 immediately on 4/27/2022. See attachment #23 for staff 7, #24 for staff 8 and #25 for staff 9 |
05/10/2022
| Implemented |
| 6400.21(b) | There is no documentation showing that the following staff members have been residents of Pennsylvania for at least 2 years, and therefore they would need an FBI Check:
- Staff #1
- Staff #2
- Staff #3
- Staff #4
- Staff #5
- Staff #6 | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Program Assistant scheduled FBI background checks of staff 1, 4, and 6 on 5/20/22. See attachment #37, 35 , 36, and 38. Staff 2,3, and 5 had prehire PA background checks done but record was misfiled and found on 5/9/22 after inspection. Please see attachment #32, 33, 34. |
05/20/2022
| Implemented |
| 6400.62(d) | There was Tylenol and Theraflu located in the kitchen cabinet along with food. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | The Tylenol and Theraflu was identified as not part of medication listed on MAR and distributed by pharmacy, it was removed immediately from the residence upon discovery on 4/27/2022. Safe storage and handling of hazardous products in relation to food items has been added to annual training checklist on 5/11/22. Please see sample new hire training checklist attachment #19. |
05/11/2022
| Implemented |
| 6400.72(b) | The bathroom window does not stay open and needs to be repaired. (When you try to open it, it will immediately slam down) | Screens, windows and doors shall be in good repair. | Program Manager called contractor on 5/3/22 to notify of the need to repair the windows in the dining room, living rooms, and both bathroom as they cannot be opened. The Program Manager scheduled the earliest available appointment for the repair completed on 5/20/2022. See attachment #21. |
05/20/2022
| Implemented |
| 6400.110(a) | There is no smoke detector located in the basement. The smoke detector is on the ceiling at the top of the basement stairs which is located on the first floor of the home. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Program Manager notified electrician on 5/3/22 to notify of the need to relocate the smoke detector at the top of the basement steps to a location further into the basement itself. The Program Manager scheduled the appointment for the adjustment which occurred on 5/3/2022. See attachment #22. |
05/03/2022
| Implemented |
| 6400.144 | In the records of individual #1 there is no indication that the medications Clindamycin Lotion and Albuterol Sulfate medications were administered as prescribed because they were not listed on the MAR, although they were filled on 3/31/22. | 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.
| On 4/27/22, Program Manager reviewed prescriptions in consumer¿s medical binder which states the directions per script by physician. On 4/27/22, MAR corrected the MAR to include the medications. Program Supervisor contacted pharmacy on 4/28/22 to notify them that future MARs need to include all prescriptions unless written discontinuation by physician is received. |
05/20/2022
| Implemented |
| 6400.166(b) | The following medications for Individual #1 were in the medication box but were not listed on the MAR:
Clindamycin Lotion (filled 3/31/22)
Albuterol Sulfate (filled 3/31/22) | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | On 4/27/22, Program Manager reviewed prescriptions in consumer¿s medical binder which states the directions per script by physician. On 4/27/22, MAR corrected the MAR to include the medications. Program Supervisor contacted pharmacy on 4/28/22 to notify them that future MARs need to include all prescriptions unless written discontinuation by physician is received. |
05/20/2022
| Implemented |