| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | This agency denied licensing representatives access to review individual #1 medications. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | All staff was trained on the licensing process and ensuring that all access will be provided upon request. If staff is unable to determine who the licensing person is request identification |
05/10/2023
| Implemented |
| 6400.21(a) | New hire staff #1 (hired 1/20/23) and #2 (hired 10/17/22) did not have a Pennsylvania criminal history background check completed. | 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.
| criminal background is completed. |
05/11/2023
| Implemented |
| 6400.21(b) | New hire staff #1 (hired 1/20/23) and #2 (hired 10/17/22) did not have a Federal criminal history background check completed. | 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.
| criminal background was completed |
05/11/2023
| Implemented |
| 6400.62(a) | There were unlocked household cleaners/poisons under the kitchen sink cabinet and all residents of this home cannot safely handle these items. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Locked storage cabinet was purchased, and signs made to store all poisonous material and cleaners in |
05/10/2023
| Implemented |
| 6400.64(a) | The oven needs a thorough cleaning. | Clean and sanitary conditions shall be maintained in the home. | all homes were cleaned |
05/11/2023
| Implemented |
| 6400.64(f) | The trash in the backyard was being stored on the ground and not in trash receptacles. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | All staff was trained in ensuring that trash should be placed inside the trash cans and not placed outside the cans to avoid bugs, rodents etc |
05/11/2023
| Implemented |
| 6400.71 | There were no emergency phone numbers by the telephone in the second floor office. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| form was created to provide telephone number and direction to the nearest hospital, police department, fire department. |
05/12/2023
| Implemented |
| 6400.77(b) | The first aid kit did not contain scissors, a thermometer or a first aid manual. | 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. | all new first aide kits were purchased, and antiseptic placed in each kit |
05/12/2023
| Implemented |
| 6400.81(k)(6) | Individual #1 does not have a mirror in their bedroom. | In bedrooms, each individual shall have the following: A mirror. | individual is not capable of having a mirror he breaks it and it is documented in the ISP |
05/12/2023
| Implemented |
| 6400.82(f) | None of the second floor bathrooms in the home contained wastebaskets, hand towels or paper towels. | 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. | all staff was educated to ensure paper towels are present. |
05/12/2023
| Implemented |
| 6400.111(a) | The fire extinguishers in the office, which is the only fire extinguisher on the second floor and the basement, which is the only fire extinguisher in the basement were a 1A-10BC rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 2-A fire extinguisher was purchased for every level |
05/11/2023
| Implemented |
| 6400.111(e) | The only second floor fire extinguisher is located in the staff office. This staff office is locked when not in use, rendering the fire extinguisher not accessible to everyone. | A fire extinguisher shall be accessible to staff persons and individuals. | fire extinguisher placed on each unit and made accessible to all staff and resident |
05/11/2023
| Implemented |
| 6400.111(f) | The second floor fire extinguisher located in the staff office had not been inspected annually by a fire safety expert. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Fire extinguishers were placed on each level and inspection completed. |
05/10/2023
| Implemented |
| 6400.113(a) | Individual #1 was not trained in fire safety. | 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. | fire safety training completed |
05/10/2023
| Implemented |
| 6400.141(a) | Individual #1 has not had a physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | physical exam was completed. |
05/11/2023
| Implemented |
| 6400.181(a) | Individual #1 has not had an assessment completed. | 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. | assessment was completed |
05/11/2023
| Implemented |
| 6400.52(a)(1) | Staff #3 only completed six training hours in the last training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | all training were completed |
05/11/2023
| Implemented |
| 6400.162(a) | Staff #3 has not been trained in medication administration, but is administering medications to individual #1. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Staff was trained on medication administration. Moving forward all staff will be trained and observed on medication administration |
05/11/2023
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medications, however, is not being seen quarterly by the prescribing 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. | psychiatric scheduled |
05/12/2023
| Implemented |
| 6400.194(a) | Individual #1's clothes are being stored in a locked staff office and their behavior support plan states that they cannot have access to their clothes, however this restrictive procedure has not been approved 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. | a restrictive committee was developed and restrictive plan will be discussed. |
05/11/2023
| Implemented |
| 6400.196(a) | Staff #3 has not been trained in individual #1's behavior support plan. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | staff has been trained on behavior plan and all staff moving forward working with individual will be trained |
05/12/2023
| Implemented |