| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The PA criminal history checks were late for several staff members. | 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.
| The two staff that were reviewed were some of the first employees of Optimal. Their state police background checks were completed more than 5 days after their hire date. In the future we will make sure that all staff complete their background checks before they begin work. We have already addressed this issue and created a form called Pre-hiring requirements checklist. This list contains all items required to be complete by new hires before they start working. Since January 2023 we have utilized this form and all our staff has completed their background checks. Our program specialist is the person tasked with monitoring compliance. |
04/24/2023
| Implemented |
| 6400.82(e) | There was no nonslip mat in the tub of the home. | Bathtubs and showers shall have a nonslip surface or mat. | All Optimal Lifestyle homes are to have non slip mats in bathtubs or shower areas. The locations that were inspected both had non slip tiles / surfaces in the shower area but we also purchased non slip mats and placed them in the homes the same day the auditor was there 4/3/2023. Program specialist is the person that will monitor and ensure non slip mats are purchased and present at all locations. |
04/03/2023
| Implemented |
| 6400.151(a) | There are no physicals for staff 1 and staff 2. | 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. | Optimal Lifestyle Inc will make sure all employees that are hired complete a physical examination. We will update our pre-hiring checklist and add the physical exam to be required before we hire an individual. This check list helps us keep track of all items to be completed by a new hire before they are scheduled for their shadowing / introduction session. Program specialist is the person responsible for tracking an overseeing compliance with this item. Program specialist and other assisting staff have been educated and aware of this requirement. |
06/20/2023
| Implemented |
| 6400.151(c)(3) | There is no verification that staff 1 and staff 2 are free from communicable diseases. | 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. | We are aware that when new employees get their physical examinations done, there needs to be proof that they are free of communicable disease. We will make sure to check the physical exam form for this statement and it has to be signed by the doctor conducting the test. We will add this requirement to our pre-hiring checklist to ensure no new hires come in touch with any individuals before they complete this requirement. This requirement is in addition to their TB test. Our program specialist is the person monitoring compliance. |
06/20/2023
| Implemented |
| 6400.46(a) | There was no fire safety training for staff 1 and staff 2. | 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. | Optimal Lifestyle will have their staff trained on fire safety by a certified trainer. Our program specialist is the person responsible for training current and future staff. Program specialist will become certified in fire safety and then train all staff. Once training is conducted each employee will sign a consent form that they were trained on this issue. The acknowledgement form will then be added to their employee folder and tracked on their Employee Documents checklist. |
06/20/2023
| Implemented |
| 6400.46(d) | There is no CPR/First Aid training for staff 1 and staff 2. | 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. | Optimal Lifestyle will make sure all of our staff is CPR trained. We have already located a trainer (third party) that will train all our staff. CPR training will be completed within the first 6 months of employment. This item will be added to our Employee Documents checklist to facilitate tracking and ensuring compliance. |
06/20/2023
| Implemented |
| 6400.52(b)(1) | The CEO has less than 12 hours of training. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | CEO will complete their 12 hours training for this year. CEO is aware of this deficiency and will make sure to complete their training. We will add a Log in the CEO folder to track all required yearly training for the CEO and keep all certificates that demonstrate completion. |
06/20/2023
| Implemented |
| 6400.169(a) | No staff has completed the medication administration training in myODP. | 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). | Optimal Lifestyle will make sure all our direct staff and program specialist complete their medication training as requested by the regulations. Our program specialist and another staff have already started their training to become trainers, so they can train the rest of the staff. In addition we are pursuing the services of a third party trainer to help with the med training for all our staff. As soon as our trainers are certified they will immediately start training the rest of the staff. Medication training will be mandatory for new employees before they start working with the individual one on one. On our pre-hiring checklist we will add medication training as an item so that we can track it. Program specialist is the role responsible for compliance with this item. |
06/20/2023
| Implemented |