| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(10) | It could not be determined at inspection if individual #1 was free from communicable disease as it was not included on physical exam dated 9/30/20. | 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. | The Program Specialist was responsible for correcting the problem.
Following the inspection, Individual #1 was seen by her PCP and cleared of communicable disease as it was not indicated on the most recent physical examination completed prior to coming into the program at PPHS. Individual #1 physical examination record was updated to include that individual is free of communicable disease. |
04/13/2021
| Implemented |
| 6400.151(c)(2) | At inspection, the Tb test for staff #1 was not completed within 2-yr timeframe, last completed 1/23/19. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The COO was responsible to correct this problem.
Staff #1 requested her most recent TB test result from her doctor and presented it to PPHS administration to update employee medical records on file. Staff #1 folder did not have a copy of the most recent PPD eventhough it was completed prior to the expiration of the one on file. |
04/06/2021
| Implemented |
| 6400.216(a) | At inspection, individual#1#'s records were kept unattended in the dining room area in an unlocked cubby hole without doors. | An individual's records shall be kept locked when unattended.
| The CEO was responsible for correcting this problem.
Immediately following inspection, a lock drawer cabinet was obtained to keep all of individual #1 program books/binders when they are not in used instead of having them in the unlocked cubby without doors. |
04/02/2021
| Implemented |
| 6400.46(d) | At inspection, staff #1's 24 hours of training was not found in record. | 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. | During inspection, twenty five (25) training hours (6 hours of in-service, 8 hours of annual re-training of ODP topics, 2 hours of CPR & First Aid, 1 hour of fire safety and 8 hours of online continue education from Health Care Quality Unit -- HCQ) were recorded for staff #1 instead of the required 24 hours. However, the inspector did not give credit for 8 hours of annual re-training of pre-service orientation topics containing ODP policies. All 25 hours of training and certificates were presented to the inspector. |
04/01/2021
| Implemented |
| 6400.213(1)(i) | At inspection, the record did not include individual#1's religious affiliation, it was, listed as unknown. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The Program Specialist was responsible for correcting the problem.
The religious affiliation of Individual #1 was unknown to PPHS which was indicated in her record because individual #1 declined to respond at he time of admission. Following the inspection, Individual #1 was again asked of her religious affiliation, at which time, she indicated she is catholic. Individual #1 personal record was immediately updated to reflect Catholic as religious affiliation. |
04/01/2021
| Implemented |