| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The first aid kit was missing gauze and tweezers. | 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. | Samaritans At Last, llc, will ensure that home have a first aid kit, and that the first aid kit contains all the items described, i.e.
(b) 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.
(c) A first aid manual shall be kept with the first aid kit.
As of 5/26/2023, a new first aid kit was placed in the property that has all the components listed above. |
06/30/2023
| Implemented |
| 6400.111(f) | The kitchen fire extinguisher's inspection is out of date. It was last inspected in April 2022. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Samaritans At Last, llc, will ensure that the fire extinguisher is inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.
As of 6/9/2023 the fire extinguisher was inspected and tagged by the fire department expert. |
06/30/2023
| Implemented |
| 6400.112(a) | The agency record did not include fire drills for the months of 1/2023 through 4/2023 at the time of the review. | An unannounced fire drill shall be held at least once a month. | Samaritans At Last, llc, will ensure that fire drills are conducted unannounced at least once a month at the participant's house.
The fire drill records were at the house at the time of inspection and have since been taken to the office for record keeping.
The fire drill records were at the house at the time of inspection and have since been taken to the office for record keeping. |
06/30/2023
| Implemented |
| 6400.112(e) | The records did not indicate if there was an asleep drill conducted with in the past year. | A fire drill shall be held during sleeping hours at least every 6 months. | Samaritans At Last, llc, will ensure that a fire drill shall be held during sleeping hours at least every 6 months.
The fire drill records were at the house at the time of inspection and have since been taken to the office for record keeping. |
05/31/2023
| Implemented |
| 6400.142(a) | Individual number 1 did not a current dental examination in the records at the time of the review. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Samaritans At Last, llc, will ensure that an individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually, while an individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. SAL will make sure that the appointments are carried out as planned.
At the time of inspection, the individual's insurance was mixed up by the carrier, by has since been rectified and all required dental examinations have been carried out. |
06/30/2023
| Implemented |
| 6400.142(f) | Individual number one did not have a written plan for dental hygiene in the records at the time of the review. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Samaritans At Last, llc, will ensure that, the participant have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. |
07/31/2023
| Implemented |
| 6400.144 | The individual had only one medication review conducted (for the year) for their psychotropic medication, which was completed on 10/6/22. | 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.
| Samaritans At Last, llc, will ensure that the Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services are planned or prescribed for the individual shall be arranged for or provided. |
06/30/2023
| Implemented |
| 6400.151(a) | Staff number 3 did complete their physical examination in 2023, last exam was dated 4/1/2021. | 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. | Samaritans At Last, llc, will ensure that any 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. |
06/30/2023
| Implemented |
| 6400.217 | The was no record on file showing a consent was completed for individual #1. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Samaritans At Last, llc, will ensure that upon acceptance into the program, a written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it, is in place.
At the time of inspection, the consent form was placed in the individual's folder but was missed due to time constraint. |
07/31/2023
| Implemented |
| 6400.34(a) | The provider did not have a record indicating if they informed and explained individual rights to the individual.. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Upon individual admission to the home and annually, Samaritans At Last, LLC (SAL) will inform individuals served of their rights and the process to report a rights violation to a designated person (Program Manager) at SAL. SAL has developed an ¿Individual Rights Notification Form¿ to document the process; the completed form will be kept for the record. SAL has the documentation to illustrate how the individuals currently served have been informed of their rights and how to report a rights violation to the program manager. |
05/31/2023
| Implemented |
| 6400.52(a)(3) | The staff # 1 did not have 24 hours of staff training for the training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | SAL will ensure that, the following shall complete 24 hours of annual training related to job skills and knowledge each year:
(1). Direct service workers
(2) Direct supervisors of direct service workers.
(3) Program specialists. |
07/31/2023
| Implemented |
| 6400.52(b)(1) | The CEO (staff #4) did not receive 12 hours of training for the agency's designated training year. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | Samaritans At Last, llc, will ensure that the management, program, administrative and fiscal staff persons shall complete 12 hours of training each year. |
07/31/2023
| Implemented |
| 6400.52(c)(1) | Staff Member number one was not trained on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 2021/2022 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | SAL will ensure that,
A. Direct service workers, Direct supervisors of direct service workers, and program specialist shall complete 24 hours of training related to job skills and knowledge each year:
B. All personnel, professional and such who are in direct contact with the participant(s), shall complete a 12-hour training every year.
Also, SAL shall ensure the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships are put in place. |
07/31/2023
| Implemented |
| 6400.52(c)(2) | Staff Member number 1 was not trained on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 2021/2022 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | SAL will ensure that the annual training hours encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the child protective services law, and the applicable protective services regulations. |
07/31/2023
| Implemented |
| 6400.52(c)(2) | Staff Member number 2 was not trained on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 2021/2022 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | SAL will ensure that the annual training hours encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the child protective services law, and the applicable protective services regulations. |
06/30/2023
| Implemented |
| 6400.52(c)(4) | Staff Member number 2 was not trained on recognizing and reporting incidents during the 2021/2022 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Samaritans At Last, llc, will ensure that the annual training hours encompasses the recognizing and reporting of incidents in accordance with the Older Adults Protective Services Act. |
06/30/2023
| Implemented |
| 6400.163(a) | Individual number 1's medication kit included an albuterol inhaler that was stored without its pharmacy label. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Samaritans At Last, llc, will ensure that Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.
The medication mentioned above was taken out of the kit by physician authorization since the participant was not utilizing the medication, which has since been discontinued. |
05/31/2023
| Implemented |
| 6400.166(a)(4) | Individual number 1's medication kit included an albuterol inhaler that was not included on their MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Samaritans At Last, llc, will ensure that a medication record is maintained, indicating each individual for whom a prescription medication is administered.
The medication mentioned above has been removed in accordance with physician directions. |
05/31/2023
| Implemented |
| 6400.166(a)(13) | Individual's number 1's 8PM administration of banophen was not signed for on their MAR on 5/7/23. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Samaritans At Last, llc, will ensure that a medication record shall be kept, and that the name and initials of the person administering the medication is included on the record.
Since 5/26/2023 the staff administering medication have been readdressed of the importance of having clear initials and names next to the prescribed medication. |
05/31/2023
| Implemented |
| 6400.169(a) | The provider's staff records did not indicate if all staff successfully completed a Department-approved medications administration course at the time of the review. Staff cannot further give medication. Agency will contract with a nurse agency to administer medications. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Samaritans At Last, llc, will ensure that all staff who delegate medication are properly trained and successfully completed a Department-approved medication administration course.
The observation notes missing from the certified medication administering staff have since been placed in their files showing compliance according to Department-approved administration course. |
06/30/2023
| Implemented |
| 6400.183(b) | The records did not indicate if at least three members of the individual plan team was present at the ISP meeting for the individual. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | Samaritans At Last, llc, will ensure that the individual plan shall be developed by an interdisciplinary team and that at least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised.
Due to covid restrictions, a virtual meeting was conducted, and persons present had their emails and participation confirmed during the meeting. |
06/30/2023
| Implemented |
| 6400.186 | Individual number one's ISP indicates poisons are kept locked. Poisons were found unlocked in several spots around the apartment. Tide detergent was found in an unlocked closet near the bathroom. Bleach and Lysol wipes were found in an unlocked cabinet beneath the sink. | The home shall implement the individual plan, including revisions. | Samaritans At Last, llc, will ensure to follow the guidelines concerning the protection of the participant from items like poisons, by making sure that all poisons are kept away and locked from reach of the participant.
Since 5/26/2023 the poisons and of alike were locked away safe from the participant's reach. The DSP's were briefed on that breach and random visits by the manager are in place to inspect any such breaches. |
05/31/2023
| Implemented |
| 6400.194(a) | The individual's behavior support plan was not meet or reviewed by a human rights team. | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | Samaritans At Last, llc, will ensure the individual's behavior support plan is reviewed by a human rights team, and that records of such are kept at the office.
We have reached out to the county to assist us to meet the ODP Human Rights requirements. |
07/31/2023
| Implemented |