| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | A Pennsylvania criminal history record check was not submitted to the State Police for Staff personal #3 who was hired on 09/02/2021. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes 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.
| Staff #3 PA State police was run on 9/2/21. Due to change in administrative personnel the hard copy did not make it to the the file and could not be located. On a staffing spreadsheet done by the previous AA, it sates that the background check was completed on 9/2/21. Staff #3 State police check was rerun on 11/1/21 upon discovery. Please see attachment #1. Assistants will file all personnel documentation daily to ensure that nothing gets misplaced. |
11/01/2021
| Implemented |
| 6400.21(b) | The FBI criminal history record check was not completed within 5 working days after staff personal #4 date of hire. | 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.
| Staff #4 who DOH is 2/15/21 record check was completed within 5 working days. Please see attachment #23. Results of the FBI record check is dated for 2/18/21. |
11/02/2021
| Implemented |
| 6400.141(a) | Individual #1 last physical examination was dated 9/01/2020, no current physical was completed or scheduled. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This individual was brought to us by another provider on 9/1/21. It was not recognized that this would be the same day the physical would expire. This individual had a previous PCP appointments but would not cooperate so they had to be rescheduled. On 9/28/21 individual #1 had a physical exam completed, however it is not on the department approved form. On 11/5/21 exam was completed and put on the correct form, doctor signed 11/10/21. Please see attachment #3. |
11/05/2021
| Implemented |
| 6400.181(a) | Individual #1 has no Assessment which is to be completed 60 calendar days after admission to the home. | 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. | During the time of inspection 11/1/21, that was the 60th day after admission. The assessment was completed by Program Coordinator on 10/29/21 and forwarded at the end of the business day on 11/1/21.Please see attachment #4. Policy change has been been made to ensure that all assessments are complete within 10 days of the due date. This will allow for extra time for approval, proper filing, and mailing if needed. Please see attachment #5. |
11/09/2021
| Implemented |
| 6400.32(d) | Staff #2 was arguing with the individual #1 while inspector and the Behavioral Specialist was present, using a tone that could be threating and condescending to the individual. | An individual shall be treated with dignity and respect. | In a statement provided by the Behavior Specialist who was present at the time of inspection, it shows individual #1 as the aggressor. Please see attachment #7. Statement does not state that staff #2 used a tone that could be threating or condescending to the individual. In speaking with the BSC it was stated that staff member #2 handled the situation appropriately even while individual #1 became more aggressive, even threating physical harm. BSC used the moment to work on strategies with the staff and individual. |
11/03/2021
| Implemented |
| 6400.32(j) | Staff personal was not wearing a mask, even after the individual #1 requested that staff wear a mask for his safety. Inspector requested that staff utilize a mask. | An individual has the right to voice concerns about the services the individual receives. | It is required that all staff wear a mask while working with an individual regardless of vaccination status. Not wearing the face mask was important to the individual and their services and must been taken seriously. Please see attachment #7. Staff will continue to be trained annually on ODP Individual Rights. Please see attachment #10. Staff will also continued to be trained on individual #1 BSP. Please see attachment #8. |
11/18/2021
| Implemented |
| 6400.162(b)(1) | Staff #2 is administering medication and has not completed a Department-approved medication administration course. | A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications. | At the time of inspection Staff #2 was awaiting remediation of module(s). Prior to this the staff had never distributed medication to individuals, Staff #2 nervously administered medication without successfully completing the requirements of the department approved medication administration training course. completing the course to become med certified. Staff #2 was scheduled for remediation activities with the nurse but decided to resign before its completion. |
11/12/2021
| Implemented |
| 6400.165(c) | Individual #1 was interviewed with staff #2 and Behavioral Specialist present. Individual stated he is not administered his medication daily. | A prescription medication shall be administered as prescribed. | It is in the individuals plan that he will make up or exaggerate a story about staff. The individual has a history of making allegations against staff in an effort to get them in trouble or to stop them from working with him. Individual will refuse his medication to say that it is not given. When individual goes on weekend home visits he does not take any of his medication with him, per mothers request. Individual does consistently refuse a certain medication (Abilify) per his mothers request. Proper documentation is logged onto the MAR including refusals. |
11/02/2021
| Implemented |
| 6400.166(a)(1) | At the time of inspection there was no (MAR) Medication Administrative Record for individual #1 kept at the home that indicates the individuals name, name of medication, dose of medication, frequency of medication to be administered for the current month October 2021 and November 2021. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | At the time of inspection, MAR's had been removed by nurse to make copies for site books and program books. Since inspection, agency has purchased a copy machine for the site that will allow copies to be made on site. Please see attachment #25. With the addition of the copy machine, this will limit staff having to travel with documents. Copies are immediately able to be made and returned to site books. October and November 2021 MAR's have been returned to on-site books. |
11/05/2021
| Implemented |
| 6400.166(c) | Medication ARIPIPRAZOLE 5mg is not being administered as prescribed. Individual stated he refuses to take this medication and staff does not administer the medication nor log refusal. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | Refusals are logged in on the MAR. Individual has been told by his mother to refuse the medication when offered. For reasons of "he's not crazy". It is on record that mom has told individual not to take the medication. The individuals was seen by two different psych doctors after the original prescribing doctor and no doctor would discontinue the medication as they felt the individual needed it for anxiety/agitation.
After providing refusal documentation to doctor, the medication was D/C on 11/12/21. Please see attachment #22. MAR has been updated accordingly. |
11/12/2021
| Implemented |
| 6400.213(1)(i) | While reviewing Individual #1 file it was discovered that there is no current, dated photograph of individual. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #1 face sheet has been updated to include picture from identification card. Please see attachment #11. The mother of this individual would not allow a picture. In the future proper communication to the SC will be made so that it can be documented in the plan. Program Cooridnator/Supervisor will ensure Program Books include all required information. |
11/05/2021
| Implemented |