| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was debris found on several cabinets in kitchen consistent with dust from the vent in the ceiling. | Clean and sanitary conditions shall be maintained in the home. | 55 PA CODE CHAPTER 6400.64(a) - Clean and sanitary conditions shall be maintained in the home.
Correction - cabinet was wiped during inspection. Cabinet under vent was wiped (see attachment G).
Future prevention - Biacon supervisor will check cabinet for cleanliness during weekly rounds |
12/27/2019
| Implemented |
| 6400.64(f) | There were bags of trash outside at the front door, not in receptacles with lids. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | 55 PA CODE CHAPTER 6400.64(f) - Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.
Correction - (Please see attachment Y and O) for town home policy . Per apartment complex's policy, trash shall be placed in provided valet provided trash receptacle. Once receptacle is full, extra trash is placed beside receptacle for pick up - pick up is daily. We are not allowed to buy extra trash bins. Please advise
Future Prevention - Please advise on how we should proceed |
12/30/2019
| Implemented |
| 6400.68(b) | The hot water temperature in the bathroom was 137.8 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 55 PA CODE CHAPTER 6400.68(b) - Hot water temperatures in bathtubs and showers may not exceed 120°F.
Correction - Biacon contacted apartment complex to adjust water temperature to lower water temperature to or at the highest 120 degrees F. Apartment complex agreed to adjust (See attachment Z-A )
Future Prevention - Biacon will continue to check water temperature and work with apartment complex to ensure water temperature does not exceed 120 degree F. |
01/07/2020
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | 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. | 55 PA CODE CHAPTER 6400.77(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.
Correction - A thermometer was placed in the first aid kit (see attachment N)
Future Prevention - Biacons supervisor will check first aid kit to ensure thermometer is present during weekly rounds. |
12/27/2019
| Implemented |
| 6400.82(f) | There were no paper towels found in the bathroom but, were later replaced during the inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | 55 PA CODE CHAPTER 6400.82(f) - Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle.
Correction - paper towel was placed in bathroom during inspection
Future prevention - Paper towel or hand towel will be in each bathroom. Biacon's supervisor will check during weekly rounds. |
12/27/2019
| Implemented |
| 6400.111(f) | The Fire extinguisher was last serviced 10/2018, no inspection date listed on the fire extinguisher. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | 55 PA CODE CHAPTER 6400.111(f) - A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.
Correction - Fire extinguisher was inspected by a fire safety expert (see attachment D and E)
Future Prevention - Biacon will ensure all fire extinguishers are inspected by a fire safety expert annually and checked for compliance every 6 months for compliance by Biacon's supervisor. |
01/03/2020
| Implemented |
| 6400.141(c)(4) | Individual #1's physical exam completed on 8/6/19 did not include a 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. | 55 PA CODE CHAPTER 6400.141(c)(4) - The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.
Correction - Hearing and Vision was noted by the physician on the physical (see attachment X). We were informed by inspector during unannounced inspection that this was acceptable - Please advise
Future Prevention - hearing and vision notation was documented by physician on the physical |
12/27/2019
| Implemented |
| 6400.50(b) | At inspection, staff explained that the DDT team conducted/provided training on the behavior support plan prior to the individual's arrival. However, request to see said training and person's attending not provided during inspection. | The home shall keep a training record for each person trained. | 55 PA CODE CHAPTER 6400.50(b) - The home shall keep a training record for each person trained.
Correction - Training sheet obtained from DDTT Behavior Specialist and placed in training record (see attachments V and W)
Future Prevention - Biacon will ensure training records from outside entities are part of our training records by requesting a copy of the training sign in sheet after training is completed. |
01/06/2020
| Implemented |
| 6400.163(d) | The prescription medications were housed in an container inside a hall closet, neither were kept locked.
Individual #1's medication Triamcinolone ace cr 0.1%-apply to eczema on trunk & extremities twice a day as needed for itchy or inflamed skin-
At inspection this medication was not found in medication box, it was later found under sink in an unlocked cabinet in the kitchen by staff during exit conference.
Prax 1% lot 1%-apply to dermatitis twice a day as needed.
At inspection this medication was not found in medication box, it was later found under sink in an unlocked cabinet in the kitchen by staff during exit conference | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 55 PA CODE CHAPTER 6400.163(d) - Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.
Correction - Medications placed in a locked container (see attachment J)
Future Prevention - Biacon will ensure that locked medication boxes are purchased on the date of admission for new consumers into our program. Locked boxes will be on site on admission date |
12/27/2019
| Implemented |
| 6400.165(c) | Individual #1's medication Lorazepam 1mg-take one tablet by mouth every morning and 2 tablets at bedtime. There was no medication found in the blister pack and not signed out for 8am dosage on medication log, not sure if the medication ran out, and there was no prescription refill found for this medication at the time of this inspecction. | A prescription medication shall be administered as prescribed. | 55 PA CODE CHAPTER 6400.165(c) - A prescription medication shall be administered as prescribed.
Correction - AM Lorazepam was administered by staff but staff did not sign out as unannounced inspection had started per staff - staff signed after inspection (see attachment U). Consumer was admitted on 12/3/19 and during this transition of consumers medication and information, last medication was given on 1/3/20 - delivery of new medication was scheduled and delivered on 1/3/20 by pharmacy (see attachment A and C).
Future Prevention - Staff will go through medication remediation to ensure proper medication administration guidelines are followed. Biacon will continue to inform pharmacy of medication running out to ensure delivery is made prior to last medication being given. |
12/27/2019
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include a current dated photograph, religious affiliation, and identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 55 CODE CHAPTER 6400.213(1)(i) - Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.
Correction - Individual #1 photograph was updated with the date photograph was taken (see attachment F). Consumers face sheet was updated to include religious affiliation, and identifying marks (see attachment H).
Future Prevention - Biacon's nurse will update all consumer records to reflect a dated photograph, religious affiliation and identifying marks 1 week after admission. |
12/28/2019
| Implemented |