| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no self-assessment completed for the home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Annual self-assessments will be be completed between June and September. |
09/30/2021
| Implemented |
| 6400.21(b) | Staff #1 who was hired on 2/16/2021 and staff #2 who was hired on 2/6/2021 did not have and FBI background check in their records. | 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.
| A statement was obtained from both staff stating that they have lived in the state of Pennsylvania for 2+ years prior to employment with this agency. |
07/25/2021
| Implemented |
| 6400.62(d) | There were various chemicals stored in the closet in the kitchen area along with food items. These included laundry detergent, Swiffer wet jet, rice, canned vegetables and water. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | The poisonous materials were removed from the closet in the kitchen closet and moved to an area outside of the kitchen. |
09/08/2021
| Implemented |
| 6400.113(a) | There was no evidence in the Individual Record that a Fire Safety Training was completed with Individual 1 upon the individual's admission to the provider on 01/22/2021. | 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. | Fire Safety training was completed with the individual on 8/25/2021. |
08/25/2021
| Implemented |
| 6400.141(a) | Individual #1 had a wellness visit on 2/26/21. Many of the required areas for regulatory compliance were not covered on the physical form. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A physical was scheduled and attended by the individual on 8/5/2021. |
08/05/2021
| Implemented |
| 6400.142(c) | The Annual Dental Exam form for individual #1, dated 06/23/2021, did not contain the dentist's name nor any information that could be used to identify the dental practice. The dentist did not print their own name; while the dentist signed the form, the signature was not legible and could therefore not satisfy this requirement. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | A business card from the dentists office was attached to the dental exam form. |
09/02/2021
| Implemented |
| 6400.142(f) | There was no Dental Hygiene plan located in Individual 1's Individual Record. While staff on site reported that Individual 1 can independently practice dental hygiene, this information was not found in Individual 1's Individual Support Plan (ISP) dated 06/28/2021. There was no other written documentation from the individual's interdisciplinary team to corroborate this claim. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | A form was developed to gather information for the dental hygiene plan. The dental staff recorded what need to be done in regards to the need for removal of teeth and and follow up with periodontist and oral surgeon. A daily routine for dental hygiene was not discussed on the form . The agency will follow up with The dental office to obtain more information for the plan. |
09/30/2021
| Implemented |
| 6400.143(a) | On a medical form from a Primary Care Physician (PCP) appointment that Individual 1 attended on 02/26/2021, the PCP recommends that Individual 1 should follow up with a Gastroenterologist for a colonoscopy. Staff on site stated that Individual 1 has declined to see a Gastroenterologist. Individual 1's Assessment dated 01/25/2021 states that the individual has a history of declining Gastroenterology appointments. There was, however, no record of these appointment refusals or continued attempts to counsel Individual 1 on the importance of following the medical advice given by their physicians. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A gastroenterology appointment was scheduled for October 20th at 3:30PM with
Dr. Drew Ronnerman, US Digestive Health in Royersford, PA. |
10/20/2021
| Implemented |
| 6400.151(a) | Staff #2 who was hired on 2/6/2021, did not have a physical completed. | 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. | Physical completed on 8/10/2021 |
07/16/2021
| Implemented |
| 6400.51(a)(1) | Staff #1 who was hired on 2/16/2021 and staff #2 who was hired on 2/6/2021 did not have orientation training prior to working in the homes. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Program manager or designee will complete program orientations with staff within the 30 day post hire date. |
10/29/2021
| Implemented |