| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #1 was hired on 12/23/21. An application for a Pennsylvania criminal history record check was not submitted to the State Police within 5 working days of Staff #1's date of hire. The application for a Pennsylvania criminal history background check was not submitted until 1/7/22. | 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 #1 record submission is currently complete. Moving forward the records will be submitted within 5 days of hire as regulation's state. |
12/02/2022
| Implemented |
| 6400.64(a) | The vent in the bathroom ceiling was covered in a significant amount of dust. | Clean and sanitary conditions shall be maintained in the home. | Staff take a broom and rag and safely clean the dust from the bathroom ceiling. |
11/11/2022
| Implemented |
| 6400.67(b) | The metal spigot in the bathtub was broken on the top where it bends, the edge was sharp and presented a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Rental office was contacted and will repair by 11.7.22. In the interim spigot was sanded down to decrease sharpness and covered to ensure safety until repairs are made. |
11/11/2022
| Implemented |
| 6400.68(b) | The water temperature in the home exceeded 120 degrees and measured at 136.7. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Rental office was contacted and will repair by 11.7.22 |
11/11/2022
| Not 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. | New first aid kits are in the home. All items are accounted for. |
11/11/2022
| Implemented |
| 6400.113(a) | Individual #1 moved into the Individual's new home on October 9, 2022. Individual #1 was not 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. | 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. | Director of residential sat with individual to go over individual's primary language or mode of communication and update individuals Face sheet to reflect what individual mode of communication and language is.
Individual had already had a 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. That date has not yet been confirmed and will be by 11.30.22. |
11/30/2022
| Implemented |
| 6400.141(a) | Individual #1 did not have a physical examination within 12 months prior to placement or within the 15-day grace period after the individual's allotted 31 days of respite care upon placement in the home. Individual #1 was placed in respite care on 6/8/22. Individual #1's 31 calendar days of allotted respite care expired on 7/9/22, Individual #1 did not have a physical examination completed until 8/24/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual currently has a physical. Director of Residential and CEO are working with staff to ensure the next physical is within the 12 month time frame. This will be confirmed by 12.2.22 |
12/02/2022
| Implemented |
| 6400.144 | Health services, such pharmaceutical, are not being arranged for or provided. Individual #1 is prescribed Buspirone 20mg twice daily for anxiety. This dose of medication was prescribed on 10/11/22. The medication was not available in the home. There were two bottles of Buspirone 10mg tablets from a previous prescription. Staff reported that the prescription was sent to the pharmacy, however the home is in the process of changing the individual's medications from being packaged in bottles to packing in blister packs and the pharmacy was "holding" all of the individual's prescriptions until the pharmacy had all of the individual's prescriptions.
Individual #1 is prescribed Dextroamp Amthamine ER 20mg at 8AM and 2PM. This medication is documented as not being available in the home at 8AM or 2PM on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 and at 8AM on 10/13/22. This medication is not available in the home. | 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.
| CEO and Director of Residential have been working to ensure establishment of care in 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. This will be corrected and implemented by 12.2.22. |
12/02/2022
| Implemented |
| 6400.151(a) | Staff #1 was hired on 12/23/21. Staff #1 did not have a physical examination within 12 months prior to employment. Staff #1's physical was completed on 12/28/21. | 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. | Staff will be going for a new physical within the next 30 days. All required documentation will be highlighted. |
11/30/2022
| Not Implemented |
| 6400.151(c)(2) | Staff #1 was hired on 12/23/21. Staff #1 had a physical examination completed on 12/28/21. The physical examination did not 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.
Staff #2 was hired on an unknown date. Staff #2 had a physical examination completed on 11/9/21. The physical examination did not Tuberculin skin testing by Mantoux method with negative results. | 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. | Staff will be going for a new physical within the next 30 days. All required documentation will be highlighted. |
11/30/2022
| Not Implemented |
| 6400.181(a) | Individual #1 was placed in the home on 6/8/22 in respite care. Individual #1's allotted 31 calendar days of respite care ran until 7/9/22. However, the provider documented the individual as a respite placement until 10/9/22. Individual #1 did not have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home. Individual #1 would have been considered a permanent placement and admitted after the respite period; compliance for this individual should have been met at that time. | 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 now has an assessment. |
11/30/2022
| Implemented |
| 6400.211(b)(1) | Individual #1's emergency information did not include the name, address, telephone number and relationship of a designated person to be contacted in case of emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Individuals face sheet and emergency plans were updated to include the name, address, telephone number and relationship of a designated person to be contacted in case of emergency. |
11/30/2022
| Not Implemented |
| 6400.211(b)(2) | Individual #1's emergency information did not include the name, address and telephone number of the individual's physician or source of health care. | Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care. | Indvidual's emergency information and lifetime medical now includes the name, address and telephone number of the individual's physician or source of health care. |
11/30/2022
| Implemented |
| 6400.211(b)(3) | Individual #1's emergency information did not include the name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Indvidual's emergency information and lifetime medical now includes the name, address and telephone number of the person able to give consent for emergency medical treatment. |
11/30/2022
| Implemented |
| 6400.211(b)(4) | Individual #1's emergency information did not include a copy of the individual's most recent annual physical examination. | Emergency information for each individual shall include the following: A copy of the individual's most recent annual physical examination.
| Individual will be taken to PCP/Family doctor by 11.25.22 to ensure the physical is complete. That record will be saved in individuals program/house book. And an electronic record will also be kept. |
12/09/2022
| Not Implemented |
| 6400.212(a) | Individual #1 had a record maintained in the home, however the record did not contain all of the required information and documents including: documents that contained the individual's height, weight, color of hair, color of eyes, identifying marks, the language or means of communication spoken or understood by the individual, the primary language used in the individual's natural home, if other than English. Primary language used in the individual's natural home , the religious affiliation, the next of kin, a current, dated photograph, incident reports relating to the individual, dental examinations, dental hygiene plans, assessments as required under §6400.181(relating to assessments), individual plan documents as required by this chapter and copies of psychological evaluations, if applicable. | A separate record shall be kept for each individual.
| Individuals face sheet and emergency plan, Assessment, and Lifetime medical history with dental hygiene plan were updated to reflect the above mentioned items. |
11/30/2022
| Implemented |
| 6400.18(c) | The individual and persons designated by the individual were not notified within 24 hours of discovery of the medication errors including: Individual #2 not receiving Latuda 40mg at 8PM, on 10/4/2022, Guanfacine on 10/4/22 at 8AM, 12N, 4PM and 8PM; on 10/5/22 at 4PM and 8PM and 10/6/22 at 8PM, Dextroamp Amthamine ER 20mg at 8AM or 2PM on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 and at 8AM on 10/13/22 and Buspirone 20 mg on 10/11/22 at 8PM, 10/12/22 at 8AM and 8PM, 10/13/22 at 8AM and 8PM and 10/14/22 at 8AM. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | Director of residential will retrain staff on incident management in the form of a refresherthat will be kept onsite as a point of reference by 12.2.22 |
12/02/2022
| Not Implemented |
| 6400.18(b)(2) | Medication errors were not reported through the Department's information management system or on a form specified by the Department with 72 hours of discovery by a staff person. Individual #2 is prescribed Latuda 40mg at 8PM, this medication was documented as not being available in the home on 10/4/2022 resulting in the medication not being administered. Individual #1 is prescribed Guanfacine 1mg four times daily at 8AM, 12N, 4PM and 8PM. This medication is documented as not being available in the home on 10/4/22 at 8AM, 12N, 4PM and 8PM; on 10/5/22 at 4PM and 8PM and 10/6/22 at 8PM resulting in the mediation being administered. Individual #1 is prescribed Dextroamp Amthamine ER 20mg at 8AM and 2PM. This medication is documented as not being available in the home at 8AM or 2PM on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 and at 8AM on 10/13/22. Individual #1 is prescribed Buspirone 20mg twice daily for anxiety. This dose of medication was prescribed on 10/11/22. The medication was not available in the home. And the individual did not receive the correct dose of medication on 10/11/22 at 8PM, 10/12/22 at 8AM and 8PM, 10/13/22 at 8AM and 8PM and 10/14/22 at 8AM. There were two bottles of Buspirone 10mg tablets from a previous prescription. Staff reported that the prescription was sent to the pharmacy, however the is in the process of changing the individual's medications from being packaged in bottles to packing in blister packs and the pharmacy was "holding" all of the individual's prescriptions until the pharmacy had all of the individual's prescriptions. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Director of Residential services will make corrections as advised and enter into EIM as necessary. |
11/30/2022
| Not Implemented |
| 6400.34(a) | Individual #1 was admitted on June 8, 2022. The home did not inform and explain individual rights and the process to report a rights violation to the individual, and person designated by the individual, upon admission to the home. | 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 has been informed of all rights and the process to report any violation, and who to report to. |
11/30/2022
| Implemented |
| 6400.46(a) | Staff #2 was hired on an unknown date and is not trained in general fire safety. | 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. | Identified staff date discovered. Staff is now trained on the above items. |
11/30/2022
| Implemented |
| 6400.46(c) | Staff #1 was hired on 12/23/21 and Staff #2 was hired on an unknown date, neither have been trained in first aid techniques. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Identified staff date discovered. Staff is now trained on the above items. |
11/30/2022
| Not Implemented |
| 6400.46(d) | Staff #1 was hired on 12/23/21 and Staff #2 was hired on an unknown date, neither have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Identified staff date discovered. Staff is being scheduled for an upcoming CPR training by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. |
11/30/2022
| Not Implemented |
| 6400.51(b)(5) | Staff #1 was hired on 12/23/21 and Staff #2 was hired on an unknown date neither have receive orientation training in job skills and knowledge, specifically implementation of the Individual Service Plan if the staff works directly with an individual. | The orientation must encompass the following areas: Job-related knowledge and skills. | Identified staff date discovered. Staff are currently trained on job skills and knowledge. |
11/30/2022
| Implemented |
| 6400.165(c) | Medications are not being administered as prescribed. Individual #1 is prescribed Dextroamp Amthamine ER 20mg at 8AM and 2PM. This medication is documented as not being available in the home at 8AM or 2PM on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 and at 8AM on 10/13/22. This medication is not available in the home and is not administered as prescribed. Individual #1 is prescribed Latuda 40mg at 8PM, this medication was not available in the home on 10/4/2022 resulting in the medication not being administered as prescribed. Individual #1 is prescribed Guanfacine 1mg four times daily at 8AM, 12N, 4PM and 8PM. This medication is documented as not being available in the home on 10/4/22 at 8AM, 12N, 4PM and 8PM; on 10/5/22 at 4PM and 8PM and 10/6/22 at 8PM resulting in the medication being administered as prescribed.
Individual #1 is prescribed Buspirone 20mg twice daily for anxiety. This dose of medication was prescribed on 10/11/22. The medication was not available in the home. There were two bottles of Buspirone 10mg tablets from a previous prescription available in the home with instructions to take one 10mg tablet twice daily. Individual #1 did not receive the correct dosage of Buspirone 20mg tablets twice daily for anxiety on Buspirone 20 mg on 10/11/22 at 8PM, 10/12/22 at 8AM and 8PM, 10/13/22 at 8AM and 8PM and 10/14/22 at 8AM. Staff reported that the prescription was sent to the pharmacy, however the pharmacy;' is in the process of changing the individual's medications from being packaged in bottles to packing in blister packs and the pharmacy was "holding" all of the individual's prescriptions until the pharmacy had all of the individual's prescriptions. This medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | CEO and Director of residential worked with the pharmacy to get those times corrected between the dates of 10.27.22-11.4.22
All staff working in the home will have a medication training review that ensures they understand the basics of medication administration including the five rights by 12.2.22 by Director of residential services. |
12/02/2022
| Implemented |
| 6400.166(a)(3) | Individual #1's medication administration record does not include the allergies of the individual. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | Medication records now state the allergies as they are or states they are unknown. |
11/30/2022
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Abilify400mg by injection monthly. This medication was not listed on Individual #1's medication administration record. Missing information includes the Individual's name, the name of the prescriber, drug allergies, the name of medication, strength of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis or purpose for the medication, including pro re nata, date and time of medication administration, name and initials of the person administering the medication, duration of treatment, if applicable, special instructions if applicable and side effects of the medication, if applicable. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | CEO and Director of residential worked with the pharmacy to get individual's name, the name of the prescriber, drug allergies, the name of medication, strength of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis and purpose for the medication, including pro re nata, date and time of medication administration
medications corrected between the dates of 10.27.22-11.4.22
All staff working in the home will have a medication training review that ensures they understand the basics of medication administration including the five rights by 12.2.22 by Director of residential services. |
12/02/2022
| Implemented |
| 6400.167(a)(1) | Staff failed to administer Individual #1's Latuda 40mg at 8PM on 10/4/2022 as the medication was not available in the home. Guanfacine 1mg at 8AM, 12N, 4PM and 8PM on 10/4/22, 4PM and 8PM on 10/5/22 and 8PM on 10/6/22 as the medication was not available in the home and Dextroamp Amthamine ER 20mg at 8AM or 2PM on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 and at 8AM on 10/13/22. | Medication errors include the following: Failure to administer a medication. | CEO and Director of residential worked with the pharmacy to get individual's name, the name of the prescriber, drug allergies, the name of medication, strength of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis and purpose for the medication, including pro re nata, date and time of medication administration
medications corrected between the dates of 10.27.22-11.4.22
All staff working in the home will have a medication training review that ensures they understand the basics of medication administration including the five rights by 12.2.22 by Director of residential services. |
12/02/2022
| Not Implemented |
| 6400.167(b) | Documentation of medication errors of medications for failure to administer Latuda 40mg at 8PM on 10/4/2022, Guanfacine 1mg at 8AM, 12N, 4PM and 8PM on 10/4/22, 4PM and 8PM on 10/5/22 and 8PM on 10/6/22, Dextroamp Amthamine ER 20mg at 8AM or 2PM on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 and at 8AM on 10/13/22 and Buspirone 20mg twice daily on 10/11 at 8PM, 10/12 at 8AM and 8PM and 10/13/22, including the follow up action taken and the prescribers response follow-up action taken and the prescriber's response, if applicable, were not kept in the individual's record. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Staff will be retrained on medication administration to ensure full compliance. |
11/30/2022
| Not Implemented |
| 6400.167(c) | Medication errors including failure to administer Latuda 40mg at 8PM on 10/4/2022, Guanfacine 1mg at 8AM, 12N, 4PM and 8PM on 10/4/22, 4PM and 8PM on 10/5/22 and 8PM on 10/6/22, Dextroamp Amthamine ER 20mg at 8AM or 2PM on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 and at 8AM on 10/13/22 and Buspirone 20mg twice daily on 10/11 at 8PM, 10/12 at 8AM and 8PM and 10/13/22 at 8AM were not reported as an incident as specified in §6400.18(b) (relating to incident report and investigation). | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | CEO and Director will review ODP trainings relative to incident management
All staff working in the home will have a medication training review and incident management review that ensures they understand the basics of medication administration, as well as the basics of incident management by 12.2.22 by Director of residential services. |
12/02/2022
| Not Implemented |
| 6400.261(a) | Individual #1 was placed in the home on 6/8/2022 as respite care. Individual #1's allotted days in respite ran until July 9, 2022. Individual #1 exceeded the allotted 31 calendar days in respite care. The provider documented Individual #1 as a respite placement until 10/9/22. | Respite care is temporary community home care not to exceed 31 calendar days in a calendar year. | This individual is now on waiver services. |
11/30/2022
| Implemented |