| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #2 hired 2/21/23 did not have a PA state background check completed until 5/18/23.
Staff #4 hired 7/4/23 did not have a PA state background check completed until 7/17/23. | 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.
| CCiD has retrained all internal/Admin staff on its criminal history record check policy on 11/06/2023. |
11/06/2023
| Implemented |
| 6400.21(b) | Staff #1 hired 5/19/23 did not receive an FBI check until 7/21/23. | 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.
| CCiD has updated its Criminal History Record Check Policy as of 11/02/2023. CCiD has retrained all internal/Admin staff on its
criminal history record check policy on 11/06/2023. |
11/06/2023
| Implemented |
| 6400.111(f) | The fire extinguisher in the kitchen was due to be inspected and approved in May 2023 and is now expired. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | CCiD ensure that all facility fire extinguisher's were inspected and approved by Schweizer fire projection co. on 10/30/2023. CCiD retrained it's house manager on 11/01/2023 on CCiD's Fire extinguisher's policy. |
10/30/2023
| Implemented |
| 6400.112(c) | The 8/8/23 fire drill is missing the time it was completed on the documentation form. | 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. | CCiD will retrain its house manager, Direct support professional's and Program specialist on its Fire Drills Policy on 11/16/23. |
11/16/2023
| Implemented |
| 6400.113(a) | Individual #1's fire safety has not been completed on an annual basis. The last fire safety training was completed on 9/1/22. | 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. | CCiD has scheduled an annual Fire Safety training w/ Tri State training and safety consultanting llc. This Fire safety Training will take place on 11/28/2023. |
11/28/2023
| Implemented |
| 6400.141(c)(7) | Individual #1 6/29/23 physical did not include a gynecological exam. | 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. | CCiD will retrain Program nurse on individual Physical examination policy on 11/20/2023. Individual #1 has completed a Gynecological examination on 10/12/2023 documented by a licensed physician. |
11/16/2023
| Implemented |
| 6400.141(c)(10) | Individual #1 6/29/23 physical exam states that this individual is free of communicable diseases, but this should state that they are not and list the specific precautions that must be taken to prevent spread of disease to other individuals. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual #1's Communicable disease has been added to2024 annual Physical exam, Universal precautions have been put in place on annual 2023 physical exam. |
10/04/2023
| Implemented |
| 6400.141(c)(14) | Individual #1 6/29/23 physical does not address medical information pertinent to diagnosis and treatement in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Pertinent medical information pertaining to diagnosis and in case of an emergency Call 911 was added to the individual's annual physical. |
10/04/2023
| Implemented |
| 6400.151(c)(3) | Direct Support Staff #5's 6/28/23 physical exam did not state if they were 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. | CCiD's Program Specialist has scheduled to be seen by a licensed physician for an updated physical on 12/01/2023 |
10/05/2023
| Implemented |
| 6400.151(c)(4) | Direct Support Staff #5's 6/28/23 physical exam did not address if there were any medical problems which might affect the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | CCiD's Program Specialist has scheduled to be seen by a licensed physician for an updated physical on 12/01/2023 |
12/01/2023
| Implemented |
| 6400.181(a) | Individual #1 has not had an assessment completed annually. The last assessment was completed 9/1/22. | 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. | Each Residential Assessment support plan has been updated within the timeframes of 6400.181a guidelines. CCiD has retrained its Program Specialist on the individual Physical Examination Policy. Policy attached. |
10/31/2023
| Implemented |
| 6400.24 | Complete Comfort ID is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #2 hired 2/21/23 did not have verification that they have resided in PA for the past 2 years, nor was an FBI check completed.
Staff #3 hired 7/31/23 did not have verification that they have resided in PA for the past 2 years, nor was an FBI check completed.
· | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | CCiD has updated its Staffing policy and retrained the hiring manager on its updated policy. All agency staff will be 18 years old or older with age verified via a state issued identification and Municipal Statistics. |
10/04/2023
| Implemented |
| 6400.34(a) | Individual #1 last signed individual rights was completed on 5/25/22. There is no verification that this individual had their rights explained to them annually in 2023. | 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. | CCiD's Individual Bill of Rights have been provided to its residential individual's and signed dated 10/11/2023. CCiD has retrained its program specialist on the informing and encouraging exercise of rights policy. CCiD Shall inform each individual of their rights verbally and in writing upon admission into a facility and annually. Please see signed Bill of rights attached. |
10/11/2023
| Implemented |
| 6400.165(g) | Individual #1 takes psychotropic medication and has not had medication reviews every three months by a licensed physician. The only reviews completed were done on 6/5/23, 8/22/23 and 9/25/23, but these reviews do not include the reason for prescribing the medication. | 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. | Psychotropic medication reviews/dates have been scheduled with a licensed physician and are in place quarterly. |
10/04/2023
| Implemented |