| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(e) | Chief Executive Officer/Program Specialist/Direct Service Worker #1, date of hire 4/6/17, had a Child Abuse Clearance completed 4/22/20. Direct Service Worker #2, date of hire 8/19/19, had a Child Abuse Clearance completed 4/6/20. Direct Service Worker #3, date of hire 3/10/20 and Direct Service Worker #4, date of hire 3/27/20, did not have Child Abuse Clearances. | If the home serves primarily individuals who are 17 years of age or younger, 23 Pa.C.S. § § 6301¿6384 (relating to the Child Protective Services Law) applies. | According to the Child Protective Services Law, CEO date of hire 4/6/17, and DSP#1 date of hire 8/19/19 did not have Child Abuse Clearances prior to serving the individuals.
According to the Child Protective Services Law, DSP #3 date of hire 3/10/20 and DSP #4 date of hire 3/27/20 did not have Child Abuse Clearances prior to serving the individuals.
CEO has since obtained the child abuse clearance completed on 4/22/20. DSP #1 has since obtained child abuse clearances completed on 4/6/20.
DSP #3 has since completed a child abuse clearance with a verification date of 4/19/21. DSP #4 has since completed a child abuse clearance with a verification date of 4/14/21. |
04/19/2021
| Implemented |
| 6400.112(c) | The fire drill records reviewed between 3/30/20 and 3/17/21 did not include the exit route used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Safe Haven Group Home created fire drill records did not have the exit route used listed on the fire drill records. Effective 4/16/20, the fire drill records have been recreated to show the exit route listed. CEO has trained current staff effective 4/18/20 to ensure that all staff are aware of the change. CEO will be responsible for monitoring all fire drill logs monthly to ensure that the exit route is being listed during the drills. |
04/18/2021
| Implemented |
| 6400.112(d) | The fire drill held 4/27/20 had an evacuation time of 3 minutes 10 seconds. The fire drill held 5/12/20 and an evacuation time of 2 minutes 57 seconds. The fire drill held 6/26/20 had an evacuation time of 3 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Safe Haven Group Home conducted a fire drill with an evacuation time of 3 minutes and 10 seconds, 2 minutes and 57 seconds and 3 minutes exact on the dates of 4/27/20, 5/12/20 and 6/26/20. On these dates staff did not utilize the stop watch as instructed in the fire drill trainings and instead estimated the times.
CEO has re-trained all staff on 4/18/21 on the use of effectively recording the evacuation times using a timer. Staff was given alternatives to use in the case of a stop watch malfunction such as timers on cellphones etc. |
04/18/2021
| Implemented |
| 6400.112(e) | Individual #2 was admitted into the home on 3/14/20. The first fire drill held during sleeping hours was conducted on 10/29/20. | A fire drill shall be held during sleeping hours at least every 6 months. | Safe Haven did not conduct a fire drill within the 6month time frame for individual #2 who was admitted on 3/14/20. The fire drill was conducted on 10/29/20 as a correction. |
04/14/2021
| Implemented |
| 6400.113(a) | Individual #1, date of admission 4/20/20, was initially trained in general fire safety training 4/27/20. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Safe Haven did not train Individual #1 on her initial start date of 4/20/20. As a correction, the individual has been trained on 4/27/20. |
04/16/2021
| Implemented |
| 6400.141(a) | Individual #1 had a physical examination completed 7/15/19 and then again 2/2/21. Individual #2, date of admission 3/14/20, had a physical examination completed 11/19/20. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 was admitted to Safe Haven Group Home with a physical examination date of 7/15/19. Due to Covid, Safe Haven Group Home was not able to get an appointment for the client in a timely manner of 7/15/20. Safe Haven corrected this violation on 2/2/21 by getting individual #1 a physical examination at the earliest convenience of the doctors office.
Individual #2 was admitted to Safe Haven Group Home without a physical examination to date. Safe Haven corrected this violation by getting individual #2 a physical examination on 11/19/20 at the earliest convenience of doctors office. |
04/17/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination completed 2/2/21 does not include vision and 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 #1 had a physical examination that did not include a vision and hearing screening. The vision screening was corrected on 2/23/20, the date of individual #1's vision appointment. The hearing screening is scheduled for 5/3/21 and will corrected on this date. |
04/19/2021
| Implemented |
| 6400.141(c)(6) | Individual #1's physical examination completed 2/2/21 and Individual #2's physical examination completed 11/19/20 did not include Tuberculin skin test by Mantoux method with negative results. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual #1 and Individual #2 had physical examinations which did not include TB test results.
CEO has scheduled TB tests for both individuals on 4/27/21. |
04/19/2021
| Implemented |
| 6400.141(c)(7) | Individual #2, date of birth 11/28/02, has not had a gynecological examination including a breast examination and a Pap test. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #2, date of birth 11/28/02 did not receive a gynecological examination including a breast examination and a pap test. This correction has been submitted to the doctor and Individual #2 will receive this exam effective 4/28/21. |
04/19/2021
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed 2/2/21 and Individual #2's physical examination completed 11/19/20, do not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Individual #1 completed an assessment on 2/2/21 that did not include an assessment of the individuals health maintenance needs and medication regimen. Individual #2 completed a physical examination on 11/19/20 that did not include an assessment of the individuals health maintenance needs and medication regimen. A correction of error was made on 4/19/21 by creating a new physical examination form that indicated space for all of these areas. On 4/19/21 staff member #2 (who assist in all appointments for clients) was trained on the new form and expectations during all doctor visits. |
04/19/2021
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination completed 2/2/21 and Individual #2's physical examination completed 11/19/20, do not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | Individual #1 completed an assessment on 2/2/21 that did not include allergies and contraindicated medications. Individual #2 completed a physical examination on 11/19/20 that did not include allergies and contraindicated medications. A correction of error was made on 4/19/21 by creating a new physical examination form that indicated space for all of these areas to be filled in by the physician. On 4/19/21, CEO has trained staff #2 (who assists on all appointments) on the new form to ensure that all areas during doctor visits will be filled out appropriately. |
04/19/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 2/2/21 and Individual #2's physical examination completed 11/19/20, do not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1 completed a physical examination that did not have medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2 completed a physical examination that did not include medical information pertinent to diagnosis and treatment in case of emergency. A correction of error was made on 4/19/21 by creating a new physical examination form that indicated space for this area to be filled in by the physician. On 4/19/21, CEO has trained staff #2 (who assists on all appointments) on the new form to ensure that all areas during doctor visits will be filled out appropriately. |
04/19/2021
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination completed 2/2/21 did not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | Individual #1 completed a physical examination that did not include special instructions the individuals diet. Individual #2 completed a physical examination that did not include special instructions for the individual's diet. A correction of error was made on 4/19/21 by creating a new physical examination form that indicated space for this area to be filled in by the physician.On 4/19/21, CEO has trained staff #2 (who assists on all appointments) on the new form to ensure that all areas during doctor visits will be filled out appropriately. |
04/19/2021
| Implemented |
| 6400.151(a) | Direct Service Worker #2 had a physical examination completed 1/25/19 and then again 3/2/21. | 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. | DSW #2 had a physical examination that extended the two years that are required for physical examinations to be completed for staff. The Violation was corrected on 3/2/21 with the second physical examination completed. |
04/14/2021
| Implemented |
| 6400.151(c)(2) | Chief Executive Officer/Program Specialist/Direct Service Worker #1, date of hire 4/6/17, had Tuberculin skin testing by Mantoux method with negative results 6/25/20. Direct Service Worker #2 had Tuberculin skin testing by Mantoux method with negative results 1/25/19 and then again 2/24/21. | 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. | CEO did not have an updated TB test before the date of the first admission of individual #2 on 3/14/20. This was corrected with a TB test / negative results on 6/25/20. DSW #2 did not have a 2nd TB test within the 2 year timeframe allotted according to 55 pa code chapter 6400.151(c) (2). This was corrected on 2/24/21 with a negative test result. |
04/14/2021
| Implemented |
| 6400.151(c)(3) | Chief Executive Officer/Program Specialist/Direct Service Worker #1's physical examination completed 3/9/21, did not include a signed statement that the staff person is free of communicable diseases. This section was left blank.
Direct Service Worker #4's physical examination, completed 3/16/20, did not include a signed statement that the staff person is free of 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. | CEO #1 had a physical examination completed on 3/9/21 but did not have the section for communicable diseases completed by the physician. This was corrected on 4/21/21 when the CEO received a note from the physician stating that the CEO #1 is free from all communicable diseases. DSP#4 completed a physical examination on 3/16/20 but did not have section for communicable diseases completed by the physician. DSP contacted the physician on 4/21/21 and will have an appointment with the physician on 4/26/21 to indicate in writing that DSP #4 is free of communicable diseases. |
04/26/2021
| Implemented |
| 6400.181(a) | Individual #1, date of admission 4/20/20, does not have an assessment completed. Individual #2, date of admission 3/14/20, had an initial assessment completed 1/5/21. | 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. | Individual #1, date of admission 4/20/20 and individual #2, date of admission 3/14/20, did not have an assessment completed within the 60 calendar days after admission that included adaptive behavior and level of skills completed within 6 months prior to the residential home. The violation of Individual #1 was corrected on 1/7/21 when individual #1 was initially assessed. The violation of individual #2 was corrected on 1/5/21 when individual #2 was initially assessed. |
04/19/2021
| Implemented |
| 6400.181(e)(7) | Individual #2's assessment completed 3/4/21, does not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Individual #2's assessment completed 3/4/21 did not include the individuals knowledge of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees and are not insulted.
On 4/20/21, the CEO made the correction by adding this information to the assessment in (written form) stating the individual's (#2) ability to acknowledge a heat source and the ability to move away from the any heat source exceeding 120 degrees or that is not insulated. |
04/20/2021
| Implemented |
| 6400.181(e)(8) | Individual #2's assessment completed 3/4/21, does not include the individual's ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Individual #2 had an assessment completed that did not include the individual's ability to evacuate in the event of a fire. A correction was made on 4/20/21, by the CEO which added the individual's ability to evacuate in the event of a fire. |
04/20/2021
| Implemented |
| 6400.181(e)(14) | Individual #2's assessment completed 3/4/21 does not include the individual's knowledge of water safety and ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual #2 had an assessment completed that did not include the individual's ability to swim and acknowledgement of water safety. A correction was made on 4/20/21, by the CEO which added the individual's acknowledgement of water safety and the individual's ability to swim to the current assessment. |
04/20/2021
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights 4/20/20. Individual #2 was informed and explained individual right 3/12/21. The rights document did not include the following rights: 6400.32(a), to not be discriminated against; 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32(i), access/security to possessions; 6400.32j to voice concerns; 6400.32(n), unrestricted/private access to telecommunications; 6400.(p), whom to share a bedroom with; 6400.(q), decorate bedroom/common areas; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home; 6400.32(t)-access to food; 6400.32(u), decisions regarding health care; 6400.32(v), rights only modified for health/safety. | 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. | Individual #1 and Individual #2 were informed of and explained of their rights, however was not given all the rights listed and required according to chapter 6400.34(a). Corrections were made 4/21/21 in which the individual rights for Safe Haven Group Home LLC., was re-written to include the missing rights. Staff #2 re-read the individual their rights after corrections were made to the document. |
04/21/2021
| Implemented |
| 6400.46(a) | Direct Service Worker #3, date of hire 3/10/20, had initial fire safety training 3/19/21. Direct Service Worker #4, date of hire 3/27/20, had initial fire safety training 3/9/21. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | DSP #3 and DSP #4 did not receive the general fire safety in the appropriate timeframe according to chapter 6400.46(a). This was an oversight by the CEO and has since been corrected on 8/2/2020 for DSP #3 and corrected on 4/23/2020 for DSP#4. In addition, all DSP'S received their yearly fire safety training by the local fire department on 3/19/21. |
04/20/2021
| Implemented |
| 6400.46(b) | Direct Service Worker #2, date of hire 8/19/19, was trained in fire safety 3/19/21. There is no record of previous fire safety training therefore, compliance could not be measured. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | DSP #2 received initial fire safety training 5/28/20 and then again on 3/19/21. The initial fire safety still did not meet the requirements in which the DSP had been trained before working with individuals. This was an oversight on the CEO and have since been corrected on 5/28/20 when DSP#2 received the initial fire safety training. |
04/20/2021
| Implemented |
| 6400.51(b)(2) | Direct Service Worker #1, date of hire 3/10/20, received training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 4/7/20. Direct Service Worker #2, date of hire 3/27/20, received training on The prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 9/30/20. | The orientation 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. | DSP#3 date of hire 3/10/20 (correction made to above information) and DSP #4 date of hire 3/27/20 (correction made to above information) did not receive their trainings for "reporting of abuse" as part of the orientation training according to chapter 6400.51(b)(2). This correction was made for DSP#3 on 4/7/20 when the DSP completed the training and the correction for DSP#4 was made on 9/30/20 when the DSP completed the training. |
04/20/2021
| Implemented |
| 6400.51(b)(3) | Direct Service Worker #1, date of hire 3/10/20, received training on individual rights regulations 4/7/20. Direct Service Worker #2, date of hire 3/27/20, received training on individual rights regulations 9/30/20. | The orientation must encompass the following areas: Individual rights. | DSP#3 date of hire 3/10/20 (correction made to above information) and DSP #4 date of hire 3/27/20 (correction made to above information) did not receive their trainings for "individual rights" as part of the orientation training according to chapter 6400.51(b)(2). This correction was made for DSP#3 on 4/7/20 and the correction for DSP#4 was made on 9/30/20 when both DSP's received this training. |
04/20/2021
| Implemented |
| 6400.51(b)(4) | Direct Service Worker #1, date of hire 3/10/20, received training on recognizing and reporting incidents on 4/7/20. Direct Service Worker #2, date of hire 3/27/20, received training on recognizing and reporting incidents on 9/30/20. | The orientation must encompass the following areas: recognizing and reporting incidents. | DSP#3 date of hire 3/10/20 (correction made to above information) and DSP #4 date of hire 3/27/20 (correction made to above information) did not receive their trainings for "recognizing and reporting incidents" as part of the orientation training according to chapter 6400.51(b)(2). This correction was made for DSP#3 on 4/7/20 and the correction for DSP#4 was made on 9/30/20 when both DSP's received the training. |
04/20/2021
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #1, date of hire 3/10/20, received training on job-related knowledge and skills on 4/7/20. Direct Service Worker #2, date of hire 3/27/20, received training on job-related knowledge and skills on 9/30/20. | The orientation must encompass the following areas: Job-related knowledge and skills. | DSP#3 date of hire 3/10/20 (correction made to above information) and DSP #4 date of hire 3/27/20 (correction made to above information) did not receive their trainings for "job related knowledge and skills" as part of the orientation training according to chapter 6400.51(b)(2). This correction was made for DSP#3 on 4/7/20 and the correction for DSP#4 was made on 9/30/20. |
04/20/2021
| Implemented |
| 6400.163(a) | Individual #2 is prescribed Noreth-Ace-Enthiny, on 4/14/21 there was no pharmacy label on the medication package. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Individual #2 is prescribed Noreth-Ace-Enthiny, which did not have a pharmacy label on the medication. As a correction, the pharmacist was contacted on 4/21/21 and a new pharmacy label was printed and placed on this prescription. |
04/21/2021
| Implemented |
| 6400.165(g) | Individual #1, date of admission 4/20/20, is prescribed Vyvanse, 60 mg to treat Attention Deficit Hyperactivity Disorder and Clonidine ER,1mg to treat Mood Disorder. Individual #1 had not had any medication reviews 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. | On 4/21/21, the Doctor who prescribes these medications was contacted and a request for the medication reviews were submitted. On this same date, a med check form was received. |
04/21/2021
| Implemented |
| 6400.169(a) | Chief Executive Officer/Program Specialist/ Direct Service Worker #1 completed the modified medication administration course on 6/25/20 but did not have medication observations completed and administered medications to Individual #1 and Individual #2. Direct Service Worker #2 completed the modified medication administration course on 6/11/20 but did not have medication observations completed and administered medications to Individual #1 and Individual #2. Direct Service Worker #3 completed the modified medication administration course on 6/2/20 but did not have medication observations completed and administered medications to Individual #1 and Individual #2. Direct Service Worker #4 completed the modified medication administration course on 7/10/20 but did not have medication observations completed and administered medications to Individual #1 and Individual #2. | 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). | On 4/13/21, the CEO was able to contact a registered nurse to immediately begin administering medications to individuals #1 & individual #2. On 4/21/21 CEO was able to contract a med-trainer to appropriately train all staff Safe Haven Group Home staff in med. administration. |
04/21/2021
| Implemented |
| 6400.181(f) | Individual #2's assessment completed 1/5/21, was not provided to the SC and plan team members for the annual ISP meeting held 2/24/21. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Individual #2 had assessment completed 1/5/21 that was not sent to the SC and plan team members for the annual ISP meeting held on 2/24/21. The correction was made on 4/20/21. The CEO sent the assessment to the SC and all plan team members VIA email, explaining that this information will be given before all annual/ ISP meetings are held. |
04/20/2021
| Implemented |
| 6400.213(1)(i) | The records for Individual #1 and Individual #2 do not include identifying marks, eye color or hair color. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. 213(1)i-vi | The records for individual #1 and Individual #2 did not include identifying marks, eye and hair color. The Correction was made on 4/15/21 adding these items to the records for both individuals. |
04/15/2021
| Implemented |