| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessments for the home were incomplete. | 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.
| Coordinator of training and Compliance will create a schedule of completion for each respective site's self assessment in accordance with expected timeline as outlined in regulations. |
01/19/2023
| Implemented |
| 6400.21(c) | The Pennsylvania State Criminal Background Check for Staff #3 was completed more than one year before their date of hire. (Date of check is 5/25/21; Date of Hire is 8/28/22) | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| Human Resources will complete all criminal background checks within the required timeframe. Criminal background checks provided will be reviewed and if criteria is not met will be updated. |
01/19/2023
| Implemented |
| 6400.76(a) | The toilet located in the basement was not mounted to the floor, which could cause a tilting hazard. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Maintenance was informed and toilet will be mounted. |
01/19/2023
| Implemented |
| 6400.111(a) | There was no operable fire extinguisher or smoke detector located in the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Fire extinguisher will be purchased by and installed by maintenance |
01/19/2023
| Implemented |
| 6400.112(c) | There is no time listed on the drill for 12/21/21.
There is no evacuation time for drill 1/22/22. | 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. | House manager will review all documents after completion of fire drill to assure form was completed in its entirety |
01/19/2023
| Implemented |
| 6400.113(a) | Ind. #1 file did not include fire safety training for the last year. | 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 will be conducted buy the Coordinator of Training and Compliance for the individual |
01/19/2023
| Implemented |
| 6400.141(a) | Ind. #1 who was admitted on 2/1/22 did not have a physical on file prior to admission. There was an examination completed on 8/22/22, however the visit summary form did not include the majority of the pertinent information required by regulation for an annual exam. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Coordinator of Training and Compliance will replace current physical form with ODP form. The House manager will schedule physical and subsequent physical two months prior due date. |
01/19/2023
| Implemented |
| 6400.141(c)(6) | Ind. #1 does not have TB results since the time of admission. It is unclear when the last TB was given. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | House Manager will schedule an appointment for TB with PCP. Documentation will be completed and placed in medical binder |
01/19/2023
| Implemented |
| 6400.144 | PRN Medication (LOPERAMINE 2MG cap) does not match the MAR, the individual #1 could be getting the wrong dosage. | 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.
| Director of Health Services will create a protocol to review medications when refilled to confirm name or if generic drug was provided. MAR will be reviewed and updated to be consistent with prescription bottles. |
01/19/2023
| Implemented |
| 6400.151(c)(3) | The physical for Staff #4 does not include a signed statement whether or not they are free of communicable diseases.
Staff #6 physical exam dated 5/6/22 did not include a statement regarding 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. | Director of Health Services will amend physical form to include signed statement informing whether or not the person is free of communicable disease or the staff ahs a communicable disease and is able to work with the necessary precautions |
01/19/2023
| Implemented |
| 6400.151(c)(4) | Staff #6 physical exam dated 5/6/22 did not include a statement regarding medical problems. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Director of Health Services will amend physical form to include signed statement regarding medical problems to confirm whether it will impede the ability to perform duties and or health of the individual |
01/19/2023
| Implemented |
| 6400.181(d) | Ind. #1 annual assessment dated 4/1/22 was not singed and dated by the program specialist. | The program specialist shall sign and date the assessment. | Program Specialist will sign the assessment |
01/19/2023
| Implemented |
| 6400.181(e)(4) | Ind. #1 annual assessment completed on 4/1/22 does not fully list the supervision level for the individual. It only gives a partial supervision level from 8am to 8pm. | The assessment must include the following information: The individual's need for supervision.
| Program Specialist will amend assessment to include individual's supervision needs as outlined in the ISP |
01/19/2023
| Implemented |
| 6400.181(e)(14) | Ind. #1 annual assessment completed on 4/1/22 did not include the individual's ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Program specialist will update assessment to include information regarding the individual's ability to swim and supervision needs as it relates to water |
01/19/2023
| Implemented |
| 6400.217 | There was no release of information for Ind. #1 | 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.
| Program Specialist will get the individual to sign a release of information. |
01/19/2023
| Implemented |
| 6400.34(b) | Ind. #1 file did not include a signed copy of the statement of rights | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | Program Specialist will review individual rights and get a signed copy |
01/19/2023
| Implemented |
| 6400.46(b) | Staff #6 was trained in fire safety by a person who was not certified as a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Coordinator Training and Compliance will identify training resource to become certified in Fire Safety |
01/19/2023
| Implemented |
| 6400.46(d) | The First Aid Training for Staff #4 expired on 7/22/22. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Training will be scheduled for staff to complete first aid training |
01/19/2023
| Implemented |
| 6400.50(a) | The training record does not contain content or certificates for trainings for staff #4 | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The Coordinator of Training will review training providers to determine how certificate are obtained. Will have staff email certificate toto Coordinator of Training and Compliance once completed. |
01/19/2023
| Implemented |
| 6400.165(b) | PRN Medication (POLYVINYL ALCOHOL 1.4%) is not on the individual #1 MAR but found in the medication box. | A prescription order shall be kept current. | House Manager will inspect medication box and remove all medication not listed on MAR |
01/19/2023
| Implemented |
| 6400.166(d) | Medication (POLYETHAYORE GLYCOL GAVILAX) pharmacy label does not match the MAR, for Ind. #1 | The directions of the prescriber shall be followed. | House Manager will review medication on MAR to confirm alignment with pharmacy label and update the MAR as needed |
01/19/2023
| Implemented |
| 6400.169(a) | Staff #6 medication administration training which took place on 8/25/22 and 8/29/22 was incorrectly completed. The score for the written part of the exam was 87 which is below the score for passing. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Coordinator of Training and Compliance will review regulations with training concerning medication administration training. Trainer will review all results to confirm accuracy |
01/19/2023
| Implemented |
| 6400.183(c) | Ind. #1 file did not include a sign in sheet for the ISP. | The list of persons who participated in the individual plan meeting shall be kept. | Program Specialist will provide list of participants to all ISP meetings to be placed in ISP Binder |
01/19/2023
| Implemented |
| 6400.186 | Ind. #1 annual ISP dated 4/6/22 and the annual assessment dated 4/1/22 indicate different levels of supervision. The ISP states 24 hours with 1:1 while the assessment lists the supervision level as 2:1 for 12 hours a day. | The home shall implement the individual plan, including revisions. | Program Specialist will amend assessment to align to supervision as outlined in ISP |
01/19/2023
| Implemented |
| Article X.1007 | The staff(s) affidavits do not indicate whether or not staff have lived in the Commonwealth of PA for the past consecutive 2 years. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Human Resources will amend affidavit to include whether or not the staff have resided in PA for the past two consecutive years. |
01/19/2023
| Implemented |