| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The ceiling as well as the vents in the ceiling in individual#1's bathroom were covered with debris and needs to be cleaned. | Clean and sanitary conditions shall be maintained in the home. | Clean and sanitary conditions shall be maintained in the home at Community mentorship. |
08/25/2022
| Implemented |
| 6400.68(b) | The water temperature in individual#1's bathroom at sink read 128.8 degrees Fahrenheit-corrected later in the day. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | At Community Mentorship Hot water temperatures in bathtubs and showers may not exceed 120°F. Individual #1¿s bathrooms sink, and tub Fahrenheit was immediately corrected post inspection on 8/25/22. |
09/16/2022
| Implemented |
| 6400.82(f) | There were no cloth or paper towels found in hall bathroom or individual's bathroom- both replaced during 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. | At Community Mentorship 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. |
09/16/2022
| Implemented |
| 6400.151(a) | Staff member#2 's physical exam was completed 7/29/22 and the date of hire was 7/27/22, which is not within the required timeframe prior to employment. | 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. | At Community Mentorship 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. |
09/16/2022
| Implemented |
| 6400.217 | The written consent of the individual or the individual's parent or guardian was not found in the record at inspection. | 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.
| At Community Mentorship 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. |
09/16/2022
| Implemented |
| 6400.24 | Residency prior to employment could not be determined for staff members 1, 2, and 3. As a result, FBI background checks must be completed in those instances, or a residency waiver must be provided. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Community Mentorship will ensure If a prospective employee 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. |
09/16/2022
| Implemented |
| 6400.34(a) | At inspection, there was no documentation that the individual was informed of their rights or what the process is to report a rights violation. There was no documentation that persons designated by the individual annually received this information either. | 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. | Community Mentorship 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. |
09/16/2022
| Implemented |
| 6400.165(c) | At inspection, none of the 8am medications (Sertraline 100mg, Vitamin d3 1000 units, Dexmethylphe er 10mg) were signed out as administered on the mar. | A prescription medication shall be administered as prescribed. | At Community Mentorship a prescription medication shall be administered as prescribed. |
09/16/2022
| Implemented |
| 6400.166(a)(13) | At inspection, none of the 8am medications (Sertraline 100mg, Vitamin d3 1000 units, Dexmethylphe er 10mg) were signed out as administered on the mar-due to the excess of medications in the blister packs at inspection, it could not be determined if the meds were given at the correct time or not. | 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. | At Community Mentorship 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. |
09/16/2022
| Implemented |
| 6400.166(b) | At inspection, none of the 8am medications (Sertraline 100mg, Vitamin d3 1000 units, Dexmethylphe er 10mg) were nrecorded as administered on the mar. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered at Community Mentorship. |
09/16/2022
| Implemented |
| 6400.167(c) | At inspection, none of the 8am medications (Sertraline 100mg, Vitamin d3 1000 units, Dexmethylphe er 10mg) were signed out as administered on the mar- it could not be determined if the medication were administered for the am dosage-this incident should be reported as a medication error. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | At Community Mentorship medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). |
09/16/2022
| Implemented |
| 6400.181(f) | The annual assessment was not sent to the sc/plan team members 30 days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | At Community Mentorship, the program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). |
09/16/2022
| Implemented |