| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | (Repeated Violation -- 4/5/22) The self-assessment completed 8/31/22 did not assess compliance with the following regulations: 6400.72a, 6400.72b, 6400.142e. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Self-assessment that was completed on 8/30/22 did not include a summary the corrections for identified violations and was missing some sections. Another self-assessment was completed on 1/20/23, however, this was outside of 3 to 6 months prior to 12.28.22, when the previous certificate of compliance expired, and therefore not compliant. The assigned staff person who completed the 8/30/22 self-assessment is no longer with GHHS. An assessment has been scheduled for 7/15/23 (expiration of cert. is 12/28/23) and is saved on the shared outlook calendar, with invites to the program management. Additionally, training has been done based on this most recent licensing findings. Attached file: Self-assessment signed training policy on scheduling self-assessments. |
05/17/2023
| Implemented |
| 6400.15(c) | The self-assessment completed on 8/31/22 did not include a plan of correction for 6400.163c and 6400.165g. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Self-assessment that was completed on 8/30/22 did not include a summary the corrections for identified violations. Another self-assessment was completed on 1/20/23, however, this was outside 3 to 6 months prior to 12.28.22, when the previous certificate of compliance expired, and therefore not compliant. The assigned staff person who completed the 8/30/22 self-assessment is no longer with GHHS. An assessment based on the recent licensing inspection has been completed (for the house that was full review) and used as part of the training process, to include corrective action. |
05/17/2023
| Implemented |
| 6400.21(d) | Staff person #2's date of hire is 3/20/23. A Pennsylvania State Police background check was completed utilizing a 3rd party vendor on 2/28/23, however the final report from the Pennsylvania State Police is not on file with the agency. | A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
| This was an oversight that was corrected on 4/5/23. A copy of the final report from the State Police was provided on 4/5/23 and is also attached as evidence. HR Director and management staff are now aware of the need to keep final report from State Police and FBI, if applicable, even when 3rd vendors are used. |
05/17/2023
| Implemented |
| 6400.22(d)(1) | (Repeated Violation - 4/5/22) Individual #1's cash disbursement and receipts ledgers are inaccurate multiple times from 5/1/22 through the 4/5/23 inspection. Multiple times, the money spent was not correctly deducted from the current total, and the correct amount from receipts are not being deducted from the total balance. According to Individual #1's April 2023 ledgers, Individual #1 should have $23.17 at the home, however, the balance was computed incorrectly on the ledger and should have been $23.20. The total money available at the home on 4/5/23 was $20.66. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The staff were retrained and evidence is attached for the current months ledger record for the same individual. The Program Manager previously assigned to this site is no longer with the company, and the newly assigned PM has been trained to supervise staff entries and compliance with this topic. |
05/17/2023
| Implemented |
| 6400.106 | (Repeated Violation - 4/5/22) As of the 4/5/23 inspection, the most recent furnace inspection and cleaning was conducted on 11/15/21. | 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.
| Most recent inspection was 1/27/23, however, this was outside the 12 months since the previous furnace inspection. Staff that were responsible to schedule and ensure completion of furnace inspection during that time period are no longer with the company. New agency management team was trained on this regulatory item to ensure annual inspection. The Program Manager has scheduled annual furnace inspection for the company owned houses, and request has been made to property manager of the rented homes, and it also saved as an appointment on the shared Outlook calendar. Inspection for 2023 has been scheduled with the furnace company and will take place on 9/5/23 and 9/6/23. Evidence is attached with signed general fire safety training scheduled furnace inspections for 9.5.23 |
05/17/2023
| Implemented |
| 6400.114(a) | At the time of the 4/5/23 inspection, there was a smoking area located at the home, however, there is no safe smoking plan in place specific to this home. | If an individual or staff person smokes at the home, there shall be written smoking safety procedures. | Staff were retrained on the Smoking and Tobacco use policy and procedure, and on the safe smoking plan as it relates to this home. A copy of the policy and procedure is kept at the site. All staff will be trained upon hire, during orientation and ongoing as needed. Attachment of signed safe smoking plan training and also general fire safety |
05/17/2023
| Implemented |
| 6400.151(a) | Staff person #2's date of hire is 3/20/23. Staff person #2's most recent physical on file was completed on 6/14/21, which is more than 12 months before their date of hire. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The violation occurred due to an oversight and was corrected on 4/7/23. HR Director and all management have been trained on ensuring that there shall be a physical examination within 12 months prior for all new hires. Evidence: Attachment signed new hire training with physicals and background checks. |
05/17/2023
| Implemented |
| 6400.151(c)(2) | Staff person #2's date of hire is 3/20/23. There is no documentation of a tuberculin test or x-ray on file for staff person #2. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The violation occurred due to an oversight and was corrected on 4/7/23. The evidence is attached. HR Director and all management have been trained on ensuring that there shall be documentation of a TB test or x-ray on file. Attachment file: Signed new hire trainings with attached physicals and background checks. |
05/17/2023
| Implemented |
| 6400.151(c)(3) | Staff person #4's 2/17/22 physical examination does not include a statement indicating that this staff person is free from communicable diseases. | 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. | The violation occurred due to an oversight and was corrected on 4/7/23. The evidence is attached. HR Director and all management have been trained on ensuring the physical examination includes a statement indicating the staff is free from communicable diseases.
Evidence: Attachment signed new hire training with physicals and background checks. |
05/17/2023
| Implemented |
| 6400.181(a) | Individual #1 had an assessment completed on 6/3/21 and not again until 12/6/22. Additionally, the 12/6/22 assessment did not include complete information required in an annual assessment. | 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. | There was an oversight in the completion of an assessment within 12 months of the previous one on 6/3/21. The assessment was also not signed and sent out to the team. The Program Manager (PM) previously assigned to the home is no longer with the company. The new PM replacement has been trained on the completion of this task according to the regulations. A recently completed signed assessment done by the PM is attached. It has also been sent out to the individual SC, family, and the individual has a copy at the house, which staff have reviewed. The next assessments are scheduled. Program Managers will be trained upon hire and annually on this topic.
Attached file: Signed individual assessment training and email.
Target date: 5/17/23 Program Manager will be responsible for the completion of this task, under the supervision of the Program Director. |
05/17/2023
| Implemented |
| 6400.181(d) | Individual #1's 12/6/22 assessment was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | The Program Manager (PM) previously assigned to the home is no longer with the company. The new PM replacement has been trained on the completion of this task according to the regulations. A recently completed signed assessment done by the PM is in Attached file: Signed individual assessment training and email. |
05/17/2023
| Implemented |
| 6400.212(a) | There was a completed release and Medication Administration Records for individual #2 in Individual #1's record. | A separate record shall be kept for each individual.
| The records were separated upon discovery that individual #2 had a record in individual #1's binder. Program Management and staff have been trained to ensure thorough processes when filing records.
Attachment file: Signed individual records training policy. |
05/17/2023
| Implemented |
| 6400.214(b) | The most recent assessment in the home for Individual #1 was dated 6/3/21. The most recent assessment in the home for Individual #2 was dated 5/31/21.
The most recent ISP in the home for Individual #1 was dated 1/9/23. Individual #1's most recent ISP update was completed on 2/22/23. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| A new assessment based on an entirely new format has been completed and sent to the team. The newly assigned Program Managers (previous PM is no longer with the company) has been trained and ensured the assessment is reviewed by staff and available on site.
Attached file: Signed individual assessment training and email. |
05/17/2023
| Implemented |
| 6400.46(b) | Staff person #4 completed annual fire safety training on 2/16/21 and not again until 10/2/22, outside of the annual timeframe. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | This training should have been completed prior to 2/16/22, and so a violation occurred as a result. The Program manager for the site is no longer with the company, and a new PM has been assigned and trained to ensure that the issue does not happen again.
Attached: signed general fire safety trainings policy. |
05/17/2023
| Implemented |
| 6400.166(b) | Individual #1's 8/13/22 and 8/14/22 doses of Omeprazole were not documented at the time of administration. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff were trained to avoid a recurrence of this violation. The staff responsible, and their assigned supervisor are no longer with the company, however, current staff and the new Program manager are trained to ensure compliance with this topic.
Attached file: Signed medication administration protocol training. |
05/17/2023
| Implemented |
| 6400.181(f) | Individual #1's 12/6/22 assessment was not sent to the team. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | There was an oversight in the completion of an assessment within 12 months of the previous one on 6/3/21. The assessment was also not signed and sent out to the team. The Program Manager (PM) previously assigned to the home is no longer with the company. The new PM replacement has been trained on the completion of this task according to the regulations. A recently completed signed assessment done by the PM is attached. It has also been sent out to the individual SC, family, and the individual has a copy at the house, which staff have reviewed. The next assessments are scheduled. Program Managers will be trained upon hire and annually on this topic.
Target date: 5/17/23 Program Manager will be responsible for the completion of this task, under the supervision of the Program Director.
Attached file: Signed individual assessment training and email. |
05/17/2023
| Implemented |