| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff person #1 was hired on 5/29/19, and their criminal history check was completed on 8/23/19, which is more than 5 days from the hire date.
Staff person #2 was hired on 7/31/19, and their criminal history check was completed on 8/23/19, which is more than 5 days from the hire date. | 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.
| To remedy the violation the Office Manager will ensure that all new hires have a background check documented in their file that has been prepared less then one year from hire or run a new check at time of hire. To prevent this from occurring in the future, this procedure shall be added to a check off list for new hires. The Office manger will be responsible to ensure the back ground is check off the list and present in the new hire file. . The Executive Director will audit the new hire file at time of hire when the file has been set up. by the office manager. |
11/15/2019
| Not Implemented |
| 6400.64(b) | There was evidence of infestation of rodents (mice droppings) located in the kitchen, primarily in the lower kitchen cabinet located on the front wall close to the front entrance. | There may not be evidence of infestation of insects or rodents in the home. | The kitchen cabinet located on the front wall has been cleaned of mice droppings. The house was exterminated August 2019 (see attached) by a professional extermination company due to sightings of mice by staff. There are no indication of mice currently at the home site. The plan to prevent future occurrence of the violation is to have the house manager conduct a weekly inspection of the house to ensure no indication of mice droppings is present and check off the inspection on the check off list at the site. If there is any indication of any findings. the House manager will in turn contact the Main office as well as the Executive Director . The Executive Director is responsible to monitor the completion of the check off list as well as inspect the site on a monthly basis and document on the monthly inspection form. |
11/15/2019
| Implemented |
| 6400.64(f) | The outside trash can did not have a lid. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | A new trash can was purchased that has a non removeable lid and placed outside the house site.. The can was purchased by the CFO at a local store.(see photo) To prevent future occurrence of the violation the House Manager is responsible to monitor on a weekly bases that the trash cans are kept closed and sign off on a check list located at the site. . In addition the Executive Director is responsible to review the list for completion and document on a monthly check off list that that this has been completed |
11/15/2019
| Implemented |
| 6400.66 | The Lighting located outside the back steps was inoperative. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The lighting fixture located outside the back steps that was inoperable has been replaced with a new fixture by the CFO to remedy the violation. (see attached photo) To prevent future occurences the house manager is responsible to inspect all lighting on a weekly bases and check off that it has been done on a check off list located at the site. The Executive Director is responsible to review the documentation and verify on a monthly bases and to document on a monthly check list that it has been done. |
11/15/2019
| Implemented |
| 6400.68(b) | The Hot water temperature in the bathtub was 127.4° Fahrenheit, and the Hot water temperature in the kitchen was 128.4° Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The Water heater temperature has been turned down and the water has been tested to reflect a temperature at 120 degrees by the house manager. To prevent future occurrence of this violation , ongoing monitoring and testing of the temperature will be done and documented by staff conducting the monthly Fire drills. . The Executive Director will in addition on a monthly bases verify the documentation as well as the temperature and document on a monthly check off list. |
11/15/2019
| Not Implemented |
| 6400.111(f) | The fire extinguisher in the kitchen had an expired inspection tag from September of 2018. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | To remedy the violation of the fire extinguisher in the kitchen with expired inspection tags , a new extinguisher was placed in the kitchen at the site by the CFO on 11/01/2019, The plan to prevent future occurrence of this violation is to have the house manager do a walk through of the house site weekly to ensure that the extinguishers are in compliance and document of a check list located at the house that this has been done, This has been implemented as of 11/1 /2019. In addition checking behind the House Manager, the Executive Director is responsible for reviewing on a monthly bases that tags are current and signing off on a check list verifying the inspection |
11/15/2019
| Implemented |
| 6400.183(5) | Individual #1's last behavior support plan was dated 8/1/18, and does not have an updated plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | An updated Behavior support plan was completed on 10/29/2019 which included a protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. The plan has been placed in the individuals Program book. . All staff working with the individual have been trained on the plan by the Behavioral Specialist., To prevent future occurrence of this violation and ensure the timely update of BSP the Office manager will monitor all files on a monthly bases to include ensuring all BS plans are up to date and check off that the BSP have been reviewed on a check off list in each individuals file. In addition the Executive Director will verify all individuals BSP are up to date and sign off on a monthly check list (see attached) |
11/01/2019
| Implemented |
| 6400.214(b) | The home did not have current records of individual #1's program or medical. They were in the office. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| To remedy the violation, a copy of the most recent records information including medical has been put in a binder and taken to the home site by the House Manager. To prevent future occurrence the plan is to ensure that a program binder is created with all record information and medical information will be placed at the site when an individual arrives. The Office Manager will ensure that all records are included in the Binder. The House manager will verify the contents of the Binder from a check off list . On a weekly basis the House manager will ensure that the binder is updated with current medical and records information. The Executive Director will monitor on a monthly bases and sign off on a check off list that all inspections have been done (See attached) on a monthly bases. |
11/15/2019
| Implemented |
| 6400.162(a) | Staff person #1, staff person #2, and staff person #3 did not have documentation of medication administration in their training files, and were administering medications for 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. | To remedy the violation that Staff #1,2,3 did not have documentation of Med Admin Cert in their training files and were administration meds are as follows:
BWS Office manager documented on the employee check off list, and ensured that current Med Admin Cert is included in staff training files. Staff 1 and 2 are currently not employed by BWS The Executive Director will review and monitor the Office Managers.documentation and all employees files at Hire and on a monthly bases. The Executive Director shall sign off that the review has been done on a check off list.
Moving forward the plan to prevent future occurrences: All staff at hire that will be required to administer meds. must provide documentation of Med certification and have a practicum completed by BWS trainer or complete a Med Admin Cert training . Office Manager will ensure that the documentation is in the training file before staff is put on schedule. The Executive Director will then review all new hires training file to ensure that the Office manager has followed procedure and sign off the new hire to be scheduled, in addition The Executive Director is responsible to review all employees files on a month;y basis as a follow-up |
11/11/2019
| Not Implemented |
| 6400.165(c) | Individual #1's medication Lamotrigine 100mg 2 tablets was not administered as prescribed on 10/24/19. The pill pack had one pill still in the pack. | A prescription medication shall be administered as prescribed. | Meds were administered and a record of the time was documented in a electronic system Caresoft, not in a paper form that was reviewed at the site. To fix the violation all MAR documentation has been fully converted to Caresoft program on November 1, 2019, Prior MAR's were done in a paper form as well as electronically during the conversion, Recent staff have been trained by the office manager at Orientation on the Caresoft program and all other staff were also trained by the Office Manager. To prevent future occurrences , all paper MARs are removed from the sites and all staff have been trained by the Office Manager and directed to use only the Caresoft program for reporting. The House Manager and Lead are responsible to monitor the records in Caresoft on a daily bases along with monitoring that meds are administered as prescribed and directed.. The Executive Director is responsible to monitor the House Manager/Leads finding and document on a check list on a monthly bases that this has been done. |
11/11/2019
| Not Implemented |
| 6400.166(b) | Individual #1's am medications of Lamotrigine 100mg 1 tablet, Primidone 250mg 1 tablet, Clobazam 20mg 1 tablet, Topiramate 100mg 1 tablet, Vimpat 200mg 1 tablet were not logged as given on 10/11/19, 10/12/19, 10/21/19, 10/22/19, 10/23/19, 10/26/19, and 10/28/19. Individual #1's pm medications of Lamotrigine 100mg 1 tablet, Primidone 250mg 1 tablet, Clobazam 20mg 1 tablet, Topiramate 100mg 1 tablet, Vimpat 200mg 1 tablet were not logged as given on 10/7/19, 10/10/19, 10/11/19, 10/20/19, 10/21/19, and 10/22/19. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Meds were administered and a record of the time was documented in the electronic system Caresoft,, not in a paper form that was reviewed at the site. To fix the violation all MAR documentation has been fully converted to the Caresoft program on November 1, 2019, Prior MAR's were done in a paper form as well as electronically during the conversion, House Managers and Lead can access the full MAR report from each site. Recent staff have been trained by the office manager at Orientation on the Caresoft program and all other staff were also trained by the Office Manager. To prevent future occurrences , all paper MARs are removed from the sites and all staff have been directed to use only the Caresoft program for reporting. The House Manager and Lead are responsible to monitor the records in Caresoft on a daily bases along with monitoring that meds are administered as prescribed and directed in a timely manner.. The Executive Director is responsible to monitor the House Manager/Leads finding and document on a check off list on a Monthly bases that this has been done. |
11/01/2019
| Not Implemented |
| 6400.167(b) | Individual #1's medication Lamotrigine 100mg 2 tablets was not administered as prescribed and only 1 tablet was administered on 10/24/19. There was no record of an incident for the medication error. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | To fix the violation a med Error #8635863 was filed in regards to only one tablet of Lamotrigine was given on 10/24/2019 where it was apparent that 2 was in the bubble .. A copy of the Med error report has been kept in the individual's records. To ensure this type of violation does not occur moving forward all Staff have had a review of medication administration procedures by BWS med certified trainer. The house manager and/or Lead has been made responsible to check meds on a daily bases. If an error is apparent an incident report will be completed in the Caresoft program, the Executive Director will be notified via email and a Med Error will be filed. In addition the Executive Director is responsible for monitoring the House Manager/Lead reporting of the meds verification weekly and use a monthly check off form to verify that all meds are being administered as prescribed at each residential site. |
11/15/2019
| Not Implemented |
| 6400.169(d) | Staff person #1, staff person #2, and staff person #3 did not have a record of the medication training they said they had completed. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | POC to fix that Records of Medication training is kept on site and at the office is as follows:
BWS Office manager has verified and documented on our employee check off list, that staff is med certified and trained , the date , the source , name of trainer and documentation that the course was successfully completed has been provided to the House manager to place in notebooks at each house site staff is eligible to work . The Executive Director has reviewed all records of Med certification and will do so on a monthly bases to ensure all documentation is current. Staff # 1 and 2 are no longer employed at BWS and staff #3 documentation is present at the sites and Main office. as of November 11, 2019 , to correct the violation.
Moving forward the plan to prevent future occurrences: All staff hired to administer meds, must provide documentation of Med certification when hired and a practicum will be required to be done by BWS Med trainer or staff must attend and complete training and document before staff is eligible to work and put on schedule. Once that is done, The office manager will sign off employee check list , provide the documentation to the house manager to verify and place in the Med Cert notebook at the house site, in addition , on a Monthly bases the Executive Director will review that all Med Cert training and documentation is located at each house site and document on a Monthly inspection list. |
11/11/2019
| Not Implemented |