| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | A bottle was found in a locked closet across from the primary first floor bathroom with its front label peeled off. The rear label on the bottle was in-tact and indicated the contents of the bottle to be Listerine. Labels on poison containers must be kept in-tact. | Poisonous materials shall be stored in their original, labeled containers. | The bottle found in the closet with the label illegible was removed immediately on 10/14/21 with no replacement needed. |
| Implemented |
| 6400.113(c) | It cannot be determined that a list of attendees present at the fire safety trainings for Individual 1 on 6/22/21 and Individual 2 on 4/13/21 were kept, as documentation was not submitted. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | A retraining was conducted for both Individual 1 and Individual 2 on 10/21/21. |
03/06/2022
| Implemented |
| 6400.141(a) | It cannot be determined that Individual 1 had a physical within a year prior to their 6/23/21 admission to the program, nor that Individual 2 had a physical within a year prior to their admission on 4/13/21. Documentation was not provided. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The CEO trained the site nurse on 10/20/21 that covered topics on 6400 Regulations, new admission physical at least obtained within a year prior to admission and annually thereafter, and a psychological evaluation that is within a ten (10) year period. |
03/06/2022
| Implemented |
| 6400.141(c)(9) | It cannot be determined that Individual 2 has had a prostate screening as documentation was not provided. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual 2 had a completed prostate exam on 12/9/21. |
03/06/2022
| Implemented |
| 6400.142(e) | Individual 1's 9/16/21 dental visit documentation includes a note from the doctor indicating a follow-up is needed for SRP. It cannot be determined that this follow-up was scheduled or completed as documentation was not submitted. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | A dental SRP follow-up for Individual 1 has been done on 12/16/21. |
03/06/2022
| Implemented |
| 6400.144 | Antacid-antigas suspension was missing from Individual 2's medications at point of inspection; the MAR calls for it to be administered as follows: "Take 15ml (1 tbsp) by mouth every two hours as needed for complaint of indigestion, gas, or heartburn [max 4 doses per day]," and describes it as a standing order. It cannot be determined that pharmaceutical services were being fully rendered for the individual. During the inspection, the agency provided a photograph showing the antacid-antigas medication has been replaced. | 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.
| Antacid-antigas suspension for Individual 2's medications was replaced on 10/14/21 |
03/06/2022
| Implemented |
| 6400.151(a) | It cannot be determined that staff member 2 had a physical within a year prior to their hire date of 4/21/21 as documentation was not provided. | 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. | The physical examination record for staff member 2 was received on 10/19/21 indicating staff member 2 is free from communicable diseases. |
03/06/2022
| Implemented |
| 6400.151(c)(3) | Staff member 2's 9/14/21 physical does not contain a signed statement from their doctor clearing them of communicable disease. | 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. | Staff member 2's physical was sent back to the physician for corrections, and it was signed on 10/19/21 showing that staff had no communicable disease. |
03/06/2022
| Implemented |
| 6400.181(d) | Individual 1's 8/9/21 assessment was not signed by the program specialist. After the inspection, the agency submitted a copy of the assessment that had been signed by the program specialist. | The program specialist shall sign and date the assessment. | The agency submitted a signed assessment by the program specialist on 10/14/21 |
03/06/2022
| Implemented |
| 6400.181(e)(3)(i) | Individual 1's 8/9/21 assessment does not clearly address their current level of performance and progress in the acquisition of functional skills. Individual 2's 5/27/21 assessment also does not clearly address their current level of performance and progress in the acquisition of functional skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | During the inspection some of the assessment pages were not scanned properly. The missing pages addressing individual 1 and individual 2¿s current level of performance and progress in the acquisition of functional skills were updated on 3/6/22. |
03/06/2022
| Implemented |
| 6400.181(e)(3)(ii) | Individual 1's 8/9/21 assessment does not clearly address their current level of performance and progress in communication. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | During the inspection some of the assessment pages were not scanned properly. The missing pages addressing individual 1¿s current level of performance and progress in communication were updated on 3/6/22. |
03/06/2022
| Implemented |
| 6400.181(e)(3)(iii) | Individual 1's 8/9/21 assessment does not clearly address their current level of performance and progress in personal adjustment. Individual 2's 5/27/21 assessment also does not clearly address their current level of performance and progress in personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | During the inspection some of the assessment pages were not scanned properly. The missing pages addressing individual 1 and individual 2¿s current level of performance and progress in personal adjustment were updated on 3/6/22. |
03/06/2022
| Implemented |
| 6400.181(e)(11) | It cannot be determined that Individual 2's file contains a psychological evaluation, as one was not provided at point of inspection. Individual 1's file does not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | Individual 2 has a psychological evaluation report on file dated on 2/17/1999 and a comprehensive psychiatric evaluation report dated on 6/28/2021. Individual 2 is on six (6) months waiting list for a psychological re-evaluation scheduled with Omni Health Services at 6934 Market St, Upper Darby, PA 19082.
Individual 1 has a psychological evaluation on file dated on 10/16/06 and a psychiatric evaluation dated on 1/28/01. A psychological re-evaluation schedule have been made. |
10/16/2021
| Implemented |
| 6400.212(b) | It cannot be determined who compiled Individual 1's lifetime medical document and entered it into the record, as it is not signed and dated. After the inspection, the agency submitted a revised copy of the individual's lifetime medical history, signed and dated 10/15/21. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| After the inspection, the compliance officer submitted a revised copy of the individual 1's lifetime medical history, signed and dated by the site nurse on 10/15/21. |
10/15/2021
| Implemented |
| 6400.46(a) | It cannot be determined that the fire safety trainings held for staff member 1 and staff member 3 on 3/18/20 and staff member 2 on 4/13/21 contained site-specific information. Agency documentation reviewed indicates the trainings were general trainings; it cannot be determined that they contained information about evacuation procedures and designated meeting places specific to the homes they would be working in. | 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. | A fire safety retraining for staff member 1, staff member 2 and staff member 3, was done on 10/21/21 covering the evacuation procedures and designated meeting places specific to the site.
The Yeadon Fire Marshall has trained the individuals and staff on 3/16/22, which addresses the following: general fire safety, evacuation procedure, responsibilities during fire drills, designated meeting place outside the site, designated meeting place in the fire safe area in the event of an actual fire, and smoking safety procedures/smoking areas at the residence.
Another training with the Yeadon Fire Marshall is scheduled for 3/24/22 for staff that were not present. |
03/16/2022
| Implemented |
| 6400.52(c)(1) | Staff member 1, staff member 3, and the CEO's 2020 training records did not include trainings on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The agency has added the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on orientation trainings as of 10/20/21.
All staff received these trainings on 10/20/21. |
03/06/2022
| Implemented |
| 6400.52(c)(2) | The CEO's 2020 training record did not include training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The Agency updated its training record and curriculum on 10/20/21 to meet the ODP required trainings. |
03/06/2022
| Implemented |
| 6400.52(c)(3) | The CEO's 2020 training record did not include training on individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The Agency updated its training record and curriculum on 10/20/21 to meet the ODP required trainings. |
03/06/2022
| Implemented |
| 6400.52(c)(4) | The CEO's 2020 training record did not include training on recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The Agency updated its training record and curriculum on 10/20/21 to meet the ODP required trainings. |
03/06/2022
| Implemented |
| 6400.163(h) | Individual 2's lorazepam was kept beyond the "discard by" date listed on the medication's prescription label: 10/2/21. His medications also included a bottle of Siltussin with an order reading: "Take 10ml by mouth every 4 hours as needed (for cough or cold to loosen phlegm/mucus) for up to 10," and staff submitted a prescription order that showed this meant it was to be administered for up to 10 days. The prescription date was listed as 4/8/21 on the medication bottle. During the inspection, staff submitted an updated MAR showing the Tussin has been discontinued, as well as a photograph showing a new blister pack of lorazepam had been obtained with a prescription date of 10/14/21. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Individual 2¿s Lorazepam was returned to the pharmacy to be discarded and was replaced with a new blister pack of Lorazepam on 10/14/21. Individual 2¿s Tussin medication was ordered to be administered for 10 days. During the inspection the MAR was updated, and the medication was discontinued. |
03/06/2022
| Implemented |
| 6400.165(g) | It cannot be determined that Individual 2 has had psychotropic medication reviews performed by a doctor every three months. The last review observed in agency documentation is dated 6/28/21. A medication review document submitted by the agency dated 7/26/21 only contained information completed by agency staff and not the individual's doctor. | 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. | Individual 2 has psychotropic medication review performed by Individual 2¿s psychiatrist regularly on a monthly basis, as individual 2 is a new patient. The medication review documents dated 6/28/21 and 7/26/21 was sent on 10/26/21 to individual 2¿s doctor and was completed and returned to the agency. |
03/06/2022
| Implemented |
| 6400.166(a)(4) | Individual 2's MAR called for Refresh P.M. ointment to be applied ¼ inch into each lower lid at bedtime, and the MAR indicates the medication has been administered daily for the months of September and October 2021. However, the house did not have this ointment on hand, and indicated they had been administering Leader brand sterile dry eye relief eye drops instead---the eye drops were in the individual's medicine kit. During the inspection, staff submitted documentation showing the Refresh ointment had been discontinued on 6/2/21 and a prescription for artificial tears had been issued on 6/3/21. The agency also submitted a revised MAR showing the updated eye drop medication orders. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Individual 2¿s Refresh P.M. ointment was discontinued in MAR and the new order for Artificial tears was transcribed in the MAR on 10/14/21 and the new medication was sent by the pharmacy. |
03/06/2022
| Implemented |
| 6400.166(a)(8) | Individual 2's MAR called for Polyethlene OTC 30 dos., with administration instructions reading: "Take 17 grams (marked on cap) in 4 -- 8 oz. of liquid by mouth daily." The house did not have a bottle of medication but instead had a box of MiraLAX Mix-In Pax, containing packets that held the medication in premeasured 17g packets. During the inspection, the agency submitted a prescription order dated 4/28/21 allowing for the MiraLAX packets. The agency also submitted a revised MAR showing an updated MiraLAX packet medication order. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Individual 2's MAR was updated on 10/14/21 to reflect the doctor¿s medication order for MiraLAX Mix-In Pax, containing packets that held the medication in premeasured 17g packets. |
03/06/2022
| Implemented |
| 6400.166(a)(9) | Individual 2's MAR did not reflect current prescription orders for their PRN 325mg acetaminophen tablets at time of inspection. The medication's prescription label, dated 4/28/21, reads: "Take two tablets (650mg total) by mouth every 6 (six) hours as needed for mild pain or temperature." The MAR, however, read: "Acetaminophen 322mg tablet -- take 2 tablet (650mg) by mouth every four hours as needed." The MAR does not indicate that the PRN was administered during the months of September or October 2021 up to the point of inspection. During the inspection, staff submitted a revised MAR showing the acetaminophen entry had been updated. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Individual 2's MAR was updated on 10/14/21 to reflect the doctor¿s medication order for Acetaminophen 322mg tablet -- take 2 tablets (650mg) by mouth every four hours as needed. |
03/06/2022
| Implemented |
| 6400.213(1)(i) | Individual 1's file does not include a record of identifying marks. That portion of their face sheet was blank. During the inspection, the agency submitted a revised face sheet that included a record of identifying marks. Individual 2's weight is listed on their face sheet as "0.0 lbs." | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual 1's face sheet was updated to indicate the identifying marks on individual 1¿s right eyebrow and submitted on 10/14/21.
Individual 2's weight was taken and was updated on the face sheet indicate individual 2¿s current weight and submitted on 10/14/21. |
03/06/2022
| Implemented |