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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's current Certificate of Compliance at the time of the renewal inspection expired 8/19/22. The agency did not complete a self-assessment of the home. The self-assessment provided indicates a start date of 8/10/22 and the end date indicates "in progress." The self-assessment provided has several regulations that are blank, to include the following: 6400.21(a) through and including 6400.25(d), 6400.42 through and including 6400.52(c)(6), 6400.61(a) through and including 6400.75(b), 6400.77(b) through and including 6400.84(a), 6400.101 through and including 6400.114(b), 6400.151(a) through and including 6400.152(c), 6400.181(b) through and including 6400.181(e)(6), 6400.181(e)(10) through and including 6400.181(f), 6400.182(a) through and including 6400.275 | 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.
| CEO/Program Specialist/ Chief Operating Officer
Conduct training with Nurse Coordinator, HR Specialist and Home Supervisors
Begin self-assessment training in the following areas over a two-month period:
¿ Incident Reporting
¿ Criminal History Record Check
¿ Individual Funds and Property
¿ Grievance Procedures
¿ Individual Rights
¿ Staffing
¿ Physical Site
¿ Fire Safety
¿ Individual Health
¿ Staff Health
¿ Medications
¿ Nutrition
¿ Assessments
¿ Plan Development/Process/Content
¿ Home Services
¿ Day Services/Recreational and Social Activities
¿ Restrictive Procedures
¿ Prohibited Procedures
¿ Individual Records
Training Staff and participants will be required to sign an acknowledgement form upon completion. The trainers will determine the dates and times for each training sessions.
¿ The Chief Executive Officer and Chief Operating Officer will begin the following virtue training sessions on 11/1/2022 through 11/30/22.
1. Incident Reporting, Individual Funds and Property, Grievance Procedures, Physical Site, Individual Health, Staff Health, Medications, Individual Health, and Nutrition
¿ The Program Specialist and Chief Operating Officer will begin the following virtue training sessions on 12/1/2022 through 12/31/22.
2. Assessments, Plan Development/Process/Content, Individual Records, Restrictive Procedures, Prohibited Procedures, Individual Rights, Fire Safety, Physical Site, and Home Services ["LRS Site Audit," dated 12/7/22, was received on 1/10/23 and reviewed 1/10/23. DPOC by HDKP, HSLS, on 1/24/2023]. |
10/19/2022
| Implemented |
| 6400.21(c) | Program Specialist #1, date of hire 11/18/2021, had a PA criminal history check, dated 9/10/2018, more than 12 months prior to date of hire. | 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.
| [DPOC: Immediately, and not to exceed 30-days following the receipt of the DPOC, the CEO, or designee, shall train all staff responsible for hiring new staff members in the requirements of 6400.21(a)-(e), to include that criminal background checks must be in compliance with the Older Adult Protective Services Act (OAPSA), that all criminal background checks for prospective employees must be completed through the electronic Pennsylvania Access To Criminal History (ePATCH) system and that criminal history checks through the use of any other system is not in compliance with 6400 regulations. Documentation of the training, to include the training source, content, dates, length of training, and staff persons attending, as required by 6400.50(a)-(b), shall be maintained. DPOC by HDKP, HSLS, on 12/29/22]. |
12/29/2022
| Implemented |
| 6400.141(c)(13) | Individual #1 had a physical examination on 11/9/2021; however the physical examination did not address allergies or contraindicated medications. This section of the physical examination form was blank. [Repeat violation 9/16/21, et. al.] | The physical examination shall include: Allergies or contraindicated medications. | A mandatory virtual meeting held included but not limited to the re-training of Direct Care Workers and Home Supervisors on the requirements of 6400.141c13. The physical examination form was modified to be more user friendly and to include the signoff of the Nurse Coordinator attesting to the completeness and accuracy of the form. [Training documentation, dated 10/7/22, for staff members related to individual physical examinations was received on 1/10/23 and reviewed 1/24/23. Updated individual physical examination form that includes a section for allergies and contraindicated medications was received on 10/25/22 and reviewed 10/25/22. DPOC by HDKP, HSLS on 1/242023]. |
10/11/2022
| Implemented |
| 6400.141(c)(15) | Individual #1 had a physical examination on 11/9/2021; however the physical examination did not address "current diet/special requirements." This section of the physical examination form was blank. [Repeat violation 9/16/21, et. al.] | The physical examination shall include:Special instructions for the individual's diet. | A mandatory virtual meeting held included but not limited to the re-training of Direct Care Workers and Home Supervisors on the requirements of 6400.141c15. In addition, the physical examination form was modified to be more user friendly and to include the signoff of the Nurse Coordinator confirming to the completeness and accuracy of the form. [Training documentation, dated 10/7/22, for staff members was received on 1/10/23 and reviewed 1/24/23. Updated individual physical examination form that includes a section for medical information pertinent to diagnosis and treatment in the event of an emergency was received on 10/25/22 and reviewed 10/25/22. DPOC by HDKP, HSLS on 1/242023]. |
10/11/2022
| Implemented |
| 6400.142(c) | Individual #1 had a dental examination on 9/8/2021; however, the written record of the dental examination does not indicate the dentist's name that completed the examination. | 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. | Individual #1¿s annual dental exam included the name of the registered dental hygienist. Individual #1 new provider is Perfect Smiles Dental of Cranberry who acquired All-About Smiles, individual #1¿s previous dental provider. [Tracking document, via Microsoft Excel Spreadsheet, that includes annual dental appointments, was received on 1/10/23 and reviewed 1/10/23. DPOC by HDKP, HSLS, on 1/24/2023]. |
10/11/2022
| Implemented |
| 6400.151(a) | Program Specialist #1, date of hire 11/18/2021, had a physical examination completed on 3/27/2022. This physical examination occurred after employment. | 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 new HR Specialist has been trained on the requirements relative to 6400.151a. During the HR Specialist initial phone screening, prospective employees for all staff positions are informed that they are required to have a physical examination within 12 months of hire, along with a Tuberculin skin test within two years.
Prospective employees are informed that if they have not had a physical examination nor a TB test within the appropriate timeframe, they will need to have them completed prior to hire date or to working within an individual's residence. [DPOC: Immediately, and not to exceed 30-days following the receipt of the DPOC, the CEO, or designee, shall train all staff responsible for hiring new staff members in the requirements of 6400.151(a)-(d), related to staff physical examinations. Documentation of the training, to include the training source, content, dates, length of training, and staff persons attending, as required by 6400.50(a)-(b), shall be maintained. DPOC by HDKP, HSLS, on 1/6/23]. |
10/24/2022
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness; however, the agency could not provide psychiatric medication reviews as required by regulation. [Repeat violation 9/16/21, et. al.] | 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. | An excel spreadsheet has been developed to monitor and track the 90-day psychiatric review requirements under 6400.165g. In addition, LRS revised its 90-day medical review form to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. [Tracking document, via Microsoft Excel Spreadsheet, that includes 90-day psychiatric medication reviews, was received on 1/10/23 and reviewed 1/10/23. A review of Individual #1's prescribed psychiatric medication, dated 10/11/22, was received on 10/24/22 and reviewed 10/24/22. DPOC by HDKP, HSLS, on 1/24/2023]. |
10/24/2022
| Implemented |
| 6400.181(f) | Individual #1 had an annual assessment completed on 5/2/22. The 5/2/22 assessment was sent to the plan team on 5/2/22 for the annual plan meeting conducted on 5/31/22. The assessment was sent to the plan team less than 30 days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | An excel spreadsheet has been developed to monitor and track individual records to ensure the timely completion of assessments, providing assessments timely to plan team members, and to ensure the issue is not systemic. [Tracking document, via Microsoft Excel Spreadsheet, that includes the completion of Individual annual assessments and providing individual assessments to plan team members at least 30 days prior to the annual ISP meeting, was received on 1/10/23 and reviewed 1/10/23. DPOC by HDKP, HSLS, on 1/24/2023]. |
10/24/2022
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Care Worker #2, date of hire 8/18/2021, does not have a Pennsylvania Criminal history check. [Repeat violation from 10/27/2020] | 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.
| As of 10/9/21, all prospective employees and new hires will have a requested Pennsylvania criminal history record obtained within 5 working days after the person¿s date of hire and kept in paper and electronic personnel file. |
10/09/2021
| Implemented |
| 6400.113(a) | There is no record of fire safety training for Individual #1 and Individual #2. | 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. | As of 10/9/21, all prospective employees and new hires will have a requested Pennsylvania criminal history record obtained within 5 working days after the person¿s date of hire and kept in paper and electronic personnel file. |
10/09/2021
| Implemented |
| 6400.141(c)(3) | The physical examination completed 11/15/2020 for Individual #1 did not include a record of immunizations. This section was left blank. The physical examination completed 11/5/2020 for Individual #1 did not include a record of immunizations. This section was left blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Legacy has hired a Nurse Coordinator that will help with the medical records responsibilities for our individuals. Also, to date, the CEO, Nurse Coordinator, DCP and administrative assistant staff are trained on the 55 PA Code Chapter 6400.141(a-c1-15).
Note: LRS used both the Allegheny Health Network EMR and the providers annual medical assessment form to satisfy compliance. In addition, the Record of immunizations are with physical assessment. See attachments. |
10/09/2021
| Implemented |
| 6400.141(c)(9) | The physical examination for Individual #1, date of birth 12/5/1975, completed 11/15/2020 does not include a prostate exam. This section of the physical examination form was marked "N/A." [Repeat violation from 10/27/2020] | The physical examination shall include: A prostate examination for men 40 years of age or older. | Legacy has hired a Nurse Coordinator that will help with the medical records responsibilities for our individuals. Also, to date, the CEO, Nurse Coordinator, DCP and administrative assistant staff are trained on the 55 PA Code Chapter 6400.141(a-c1-15).
Note: LRS used both the Allegheny Health Network EMR and the providers annual medical assessment form to satisfy compliance. The MD answer to the prostate exam is written in the comment section.[A picture copy the individual's EMR will be sent to the Director by the provider] |
10/09/2021
| Implemented |
| 6400.141(c)(11) | The physical examination for Individual #2 completed 11/5/2020 did not address an assessment of health maintenance needs, medication regimen, and the need for blood work at recommended intervals. This section was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Legacy has hired a Nurse Coordinator that will help with the medical records responsibilities for our individuals. Also, to date, the CEO, Nurse Coordinator, DCP and administrative assistant staff are trained on the 55 PA Code Chapter 6400.141(a-c1-15).
Note: The Intervals for lab work and medication regimen were noted in individual #2¿s EMR. |
10/09/2021
| Implemented |
| 6400.141(c)(12) | The physical examination for Individual #2 completed 11/5/2020 did not address physical limitations. This section was left blank. [Repeat violation from 10/27/2020] | The physical examination shall include: Physical limitations of the individual. | Legacy has hired a Nurse Coordinator that will help with the medical records responsibilities for our individuals. Also, to date, the CEO, Nurse Coordinator, DCP and administrative assistant staff are trained on the 55 PA Code Chapter 6400.141(a-c1-15).
Note: The physical limitations are documented in Individual #2¿s EMR. |
10/09/2021
| Implemented |
| 6400.141(c)(13) | The physical examination for Individual #2 completed 11/5/2020 did not address allergies or contraindicated medications. This section was left blank. [Repeat violation from 10/27/2020] | The physical examination shall include: Allergies or contraindicated medications. | Legacy has hired a Nurse Coordinator that will help with the medical records responsibilities for our individuals. Also, to date, the CEO, Nurse Coordinator, DCP and administrative assistant staff are trained on the 55 PA Code Chapter 6400.141(a-c1-15).
Note: Allergies and medications are documented in Individual 2¿s EMR. |
10/09/2021
| Implemented |
| 6400.141(c)(14) | The physical examination for Individual #2 completed 11/5/2020 did not address medical information pertinent to diagnosis & treatment in case of emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Legacy has hired a Nurse Coordinator that will help with the medical records responsibilities for our individuals. Also, to date, the CEO, Nurse Coordinator, DCP and administrative assistant staff are trained on the 55 PA Code Chapter 6400.141(a-c1-15).
Note: Medical information pertinent to diagnosis & treatment in case of emergency are documented in Individual #2¿s EMR. |
10/09/2021
| Implemented |
| 6400.141(c)(15) | The physical examination for Individual #2 completed 11/5/2020 did not include any information or special instructions regarding his current diet. This section was left blank. | The physical examination shall include:Special instructions for the individual's diet. | Legacy has hired a Nurse Coordinator that will help with the medical records responsibilities for our individuals. Also, to date, the CEO, Nurse Coordinator, DCP and administrative assistant staff are trained on the 55 PA Code Chapter 6400.141(a-c1-15).
Note: Special instructions regarding diet are documented in Individual 2¿s EMR. |
10/09/2021
| Implemented |
| 6400.142(a) | The physical examination for Individual #1 had a dental exam on 5/12/2021 but no record for a pervious dental exam, therefore compliance can not be measured. Individual #2 does not have a record of dental examinations. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | As of 10-18-21, all individuals 18 years of age will have a dental examination performed by a licensed dentist annually. |
10/09/2021
| Implemented |
| 6400.151(c)(3) | Direct Care Worker #1's 1/19/2021 physical examination form does not include a statement that she is free of 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. | As of 10/9/21, the pre-employment physical examination form has been updated to include a question the prospective employee is free of communicable disease. Yes or No. It appears that Direct Care Worker #1¿s pre-employment physical form was completed using the old form. [A copy of the updated form will be forwarded to the Director on 10/19/21} |
10/09/2021
| Implemented |
| 6400.181(e)(5) | Individual #1's 4/30/2021 assessment does not address the ability to self-administer medications. This section states, "See MAR data." No MAR data is attached. | The assessment must include the following information: The individual's ability to self-administer medications. | To correct this action, Program Specialist corrected Individual #1¿s assessment to include the ability to self-administer medications. |
10/09/2021
| Implemented |
| 6400.181(e)(6) | Individual #1's 4/30/2021 assessment does not address the ability to use or avoid poisonous substances. Individual #2's 8/5/2021 assessment does not address the ability to use or avoid poisonous substances. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | To correct this action, Program Specialist corrected Individual #1¿s assessment to include the ability to self-administer medications. |
10/09/2021
| Implemented |
| 6400.181(e)(12) | Individual #1's 4/30/2021 assessment does not address recommendations for specific areas of training, programming, and services. Individual #2's 8/5/2021 assessment does not address recommendations for specific areas of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | To correct this action, Program Specialist corrected Individual #1¿s assessment to include the ability to self-administer medications. |
10/09/2021
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's 4/30/2021 assessment does not address managing personal property. Individual #2's 8/5/2021 assessment does not address managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | To correct this action, Program Specialist corrected Individual #1 and Individual #2¿s assessment to address managing personal property. |
10/09/2021
| Implemented |
| 6400.15(b) | The agency used the Self-Inspection and Declaration Tool to measure and record compliance at the home instead of the Department's Licensing Inspection Instrument. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | 15 (b) a Self-Inspection and Declaration Tool was used to measure and record compliance with the 6400 regulations in error. The required Self-Assessment Licensing Inspection Instrument will be used prior to the agency¿s annual inspection. |
10/09/2021
| Implemented |
| 6400.18(a)(3) | Incident # 8855713 for a hospitalization involving Individual #2, has a discovery date of 5/20/2021 at 10:00 am was reported through the Departments information management system on 5/28/2021 at 2:46 am. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital.
| As of 10/18/21, all staff will be required to take and complete the training to assist providers with meeting the Orientation and Annual Training requirements set forth in applicable regulations and in Incident Management Bulletin 00-21-02. |
10/18/2021
| Implemented |
| 6400.18(a)(8) | Incident # 8712752 for Law Enforcement Activity, involving Individual #1, has a discovery date of 7/6/2020 at 10:30 pm was reported through the Department's Incident management system on 7/8/2020 at 6:59 pm. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| As of 10-15-21, the incident report was finalized after seeking assistance from both the help desk and Department staff. There was a technical glitch within incident management system preventing LRS from finalizing and/or submitting an extension request. |
10/18/2021
| Implemented |
| 6400.18(g) | Incident # 8887446 for Abuse, involving Individual #3, has a discovery date of 8/5/2021. the agency began the First Section of an incident report entry in EIM on 8/6/2021 at 4:35 am and has yet to complete the entry as of 9/24/2021, indicating an investigation has not yet been initiated by the agency. When requested the agency did not produce a certified investigation regarding this incident. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | As of 10-15-21, LRS continues to seek technical guidance from both the help desk and DHS support. |
10/19/2021
| Implemented |
| 6400.18(i) | Incident # 8712752 for Law Enforcement Activity, discovery date 7/7/2020, involving Individual #1 has not been finalized and no extension has been requested as of 9/24/2021. Incident # 8764158 for Law Enforcement Activity, with a discovery date of 11/7/2020, involving Individual #1 has not been finalized and no extensions have been filed as of 9/24/2021. Incident # 88221754 for Abuse, with a discovery date of 3/16/2021, involving Individual #1, has not been finalized and no extension has been filed as of 9/24/2021. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | As of 10-15-21, all incident reports were finalized after seeking assistance from both the help desk and Department staff. There was a technical glitch within incident management system preventing LRS from finalizing and/or submitting an extension request. |
10/15/2021
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications for a diagnosis of antipsychotic and depression and Individual #2 is prescribed medications for a diagnosis of anxiety there are no records of 3 month medications reviews for Individual #1 or Individual #2. | 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 #1 does have his quarterly medication reviews. [A copy of Individual #1 quarterly review will be sent to the Director by the provider. |
10/09/2021
| Implemented |
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|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #1, date of hire 6/12/2020, had a Pennsylvania criminal history record check requested on 10/24/2020; however, this request exceeded 5 working days after the person's date of hire. Direct Service Worker #2, date of hire 6/12/2020, had a Pennsylvania criminal history record check requested on 7/7/2020; however, this request exceeded 5 working days after the person's date of hire. Direct Service Worker #3, date of hire 10/5/2020, had a Pennsylvania criminal history record check requested on 10/24/2020; however, this request exceeded 5 working days after the person's date of hire. | 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.
| There will be a requested Pennsylvania criminal history record check completed within 5 working days after the person¿s date of hire. This regulation is important because it protects individuals from abuse and mistreatment. Based on the licensing inspection Summary, Direct Service Worker #1, #2 and #3 OAPSA criminal record checks were not completed within 5 working days of hire. To correct this violation the Program Compliance Director submitted Direct Service Workers #1, #2 and #3 Pennsylvania criminal history record checks on 10-24-20. The CEO will be trained to comply with 55 PA. Code Chapter 6400 regulation specified in subsection 21 (a). The training will include the importance of all perspective employees submitting a PA criminal history within 5 working days. Furthermore, the CEO will update the organizations Staff Training Employee file checklist to include the filing and monitoring of PA criminal history checks. The CEO will audit file quarterly to assure all newly hired candidates criminal record checks have been completed within the 5 working days of hire. [Immediately, the CEO, or designee, will be trained on the requirements, including timeliness, of completing employee criminal background checks within 5 working days from the date of hire, as required by 6400.21(a)-(e). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall conduct an audit of employee files to ensure that criminal background checks are completely timely. DPOC by HDKP, HSLS on 1/28/2021]. |
10/24/2020
| Implemented |
| 6400.21(c) | Direct Service Worker #4, date of hire 5/11/2020, had a Pennsylvania criminal history record check requested on 7/6/2018; however, this request exceeded one year prior to the staff person's date of hire. | 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.
| There shall be a requested Pennsylvania FBI criminal history record check within 1 year prior to the person¿s date of hire. This regulation is important because it protects individuals from abuse and mistreatment. Based on the Licensing Inspection Summary, direct service worker #4 OAPSA Pennsylvania and FBI criminal history record check was the past 1 year of hire date. To correct this violation the Program Compliance Director submitted Direct Service Worker #4 Pennsylvania criminal and FBI record checks on 10-24-20. The CEO will be trained to comply with 55 PA. Code Chapter 6400 regulation specified in subsection 21 (c). The training will include the importance of all perspective employees submitting a PA criminal and FBI clearance within a year prior to date of hire. Furthermore, the CEO will update the organizations Staff Training Employee file checklist to include filing and monitoring of PA criminal history checks. The CEO shall audit file quarterly to ensure newly hired candidates criminal record and FBI clearances are completed and accurate. [Immediately, the CEO, or designee, shall be trained on the requirements, including timelines, of employee criminal background checks, as required by 6400.21(a)-(e). Documentation of training shall be kept. Immediately, and quarterly for a period of one year, the CEO, or designee will complete an audit of all employee files to ensure that criminal background checks have been completed timely. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
10/24/2020
| Implemented |
| 6400.63(a) | The hot water temperature in the bathroom sink measured 126.8 degrees Fahrenheit at approximately 2:20 PM. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | There shall be proper heat sources that do not exceed past 120.0 degrees Fahrenheit. This regulation is important because it minimizes burn risks and safety hazards potentially caused by accessible heat sources. Based on the licensing Inspection Summary the hot water temperature in the kitchen sink measured 126.8 degrees Fahrenheit at approximately 2:20 PM. To correct the violation maintenance staff adjusted the hot water temperature to 110.0 degrees Fahrenheit. An HVAC hot water digital thermometer was purchased for all the homes to better assist with regulating water temperatures. The Program Compliance Director and CEO will be trained on how to properly assess water temperatures to comply with 55 Pa Code Chapter 6400 regulations specified in subsections 63(a). LRS Agency Maintenance Supervisor trained Direct Care Staff how to properly do temperature checks to assure the temperature does not exceed 120.0-degree Fahrenheit. LRS staff checked three times a day to assure the water temperature did not exceed 120.0 degrees Fahrenheit for one week in all the homes. The CEO will request and review weekly documented water temperature checks to ensure compliance. [Immediately, the CEO, or designee, shall train all staff on heat sources, to include the maximum water temperature of 120 degrees Fahrenheit. At least weekly, for a period of 6 months, the agency shall ensure the heat sources, to include water temperature, do not exceed 120 degrees Fahrenheit. Documentation of weekly temperature checks shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
10/23/2020
| Implemented |
| 6400.141(a) | Individual #1, date of admission 8/15/2020, had a physical examination on 10/8/19. The individual's next physical examination was scheduled for 11/5/2020. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | An individual shall have a physical examination with 12 months prior to admission and annually thereafter. To correct the violation Legacy Residential updating staff training manual to include the importance of physicals completed at admission and annual physicals to comply with 55 PA Code 6400 regulations specified in subsection 141(a). This regulation is important because early medical information helps homes decide whether an individual¿s medical needs can be met. It also helps with developing accurate assessments for individuals¿ medical needs to be met. The CEO will update the organization¿s Medical Management Program policy and procedures manual to include all proper monitoring of physical examinations and completions within 365 days of the most recent medical evaluation. The Program Compliance Director will audit all homes medical program books quarterly for completed, verifiable and timely physical assessments. [Immediately, the CEO, or designee, shall train all staff on the requirements of individual physical examination, to include required timelines, as required by 6400.141(a)-(d). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all individual medical records to ensure that individual physical examinations are completed timely and include the information as required by regulation 6400.141(c)(1)-(15). Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
11/05/2020
| Implemented |
| 6400.141(c)(4) | Individual #1, date of admission 8/15/2020, had a physical examination on 10/8/19; however, this physical examination did not include a hearing and/or vision screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | An individual physical examination shall include a vision and hearing screening for individuals over the age of 18/ years old. To correct this violation Legacy Service training manual will include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 141(c)4. This regulation is important because accurate medical information is essential to best serving individuals, developing plans and ensuring that individual medical needs are met. The CEO will update the organization¿s Medical Management policy and procedures manual to include proper monitoring of physical examinations to ensure all pertinent medical(hearing and vision) information is assessed and included on the physical form for all individuals 18 years of age or older. The Program Compliance Director will audit all home medical books for completed and verifiable physical assessments highlighting areas of vision and hearing screenings unless otherwise as recommended by physician. [Immediately, the CEO, or designee, shall train all staff on the requirements of individual physical examination, to include required timelines, as required by 6400.141(a)-(d). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all individual medical records to ensure that individual physical examinations are completed timely and include the information as required by regulation 6400.141(c)(1)-(15). Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
11/05/2020
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 8/15/2020, had a Tuberculin evaluation via Mantoux method dated 1/7/19; however, this evaluation did not include when the test was planted, when the test was read, whom completed the Tuberculin evaluation, and/or the credentials of the person whom completed the reading. Individual #2, date of admission 5/5/2020, had physical examination on 6/1/2020; however, the physical examination did not include a Tuberculin evaluation. | 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. | An individual physical examination shall include Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals over 1 years of age or positive results with noted check x-ray with recommendations. To correct this violation Legacy Service training manual will include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 141(c)6. This regulation is important as accurate medical information is essential to minimizing risk and reducing the spread on communicable disease. The CEO will update the organization¿s Medical Management policy and procedures manual to include all proper documentation and monitoring of Individual Health physical examinations regarding TB tests every 2 years. The Program Compliance Director will audit all homes medical books to ensure completed physical exams include TB test according to regulation recommendations. [Immediately, the CEO, or designee, shall train all staff on the requirements of individual physical examination, as required by 6400.141(a)-(d). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all individual medical records to ensure that individual physical examinations are completed timely and include the information as required by regulation 6400.141(c)(1)-(15), to include a Tuberculin evaluation every two years. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
11/30/2020
| Implemented |
| 6400.141(c)(9) | Individual #1, date of admission 8/15/2020, had a physical examination on 10/8/19; however, this physical examination did not include prostate examination or an acceptable Prostate-Specific Antigen (PSA) result. Individual #1 is more than 40-years old. Individual #2, date of admission 5/5/2020, had a physical examination on 6/1/2020; however, this physical examination did not include prostate examination or an acceptable Prostate-Specific Antigen (PSA) result. Individual #2 is more than 40-years old. | The physical examination shall include: A prostate examination for men 40 years of age or older. | An individual physical examination will include a prostate examination for individuals over 40 years of age or older. To correct this violation Legacy Residential Services training manual shall include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 141(c)9. Individual #1 PCP elected to not have a prostate examination completed at the 11-5-2020 appointment. Individual #2 PCP¿s stated a prostate examination was not a required to be completed at the time of the assessment. This regulation is important as accurate medical examinations are essential to the care of the Individuals. The CEO will update the organization¿s Medical Management policy and procedures manual to include all proper monitoring of Individual physical examinations include prostate examination or an acceptable Prostate Specific Antigen. The Program Compliance Director will audit all homes medical books for completed and verifiable individual physical assessments to include prostate examinations for individuals 40 years of age or older, unless otherwise recommended by physician. [Immediately, the CEO, or designee, shall train all staff on the requirements of individual physical examination, to include required timelines, as required by 6400.141(a)-(d). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all individual medical records to ensure that individual physical examinations are completed timely and include the information as required by regulation 6400.141(c)(1)-(15), to include a digital Prostate examination or acceptable Prostate-Specific Antigen (PSA) for male individuals 40-years of age or older. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
11/05/2020
| Implemented |
| 6400.141(c)(12) | Individual #1, date of admission 8/15/2020, had a physical examination on 10/8/19; however, this physical examination did not address physical limitations of the individual. Individual #2, date of admission 5/5/2020, had physical examination on 6/1/2020; however, the physical examination did not address physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | An individual physical examination shall include physical limitations. To correct this violation Legacy Service training manual will include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 141(c)12. This regulation is important as accurate medical information is essential to develop accurate plans of care for individuals. The CEO will update the organization¿s Medical Management policy and procedures manual to include all proper monitoring of physical examinations ensuring they address physical limitations. The Program Compliance Director will audit all homes medical books to ensure all physical examinations include the individual¿s physical limitations. [Immediately, the CEO, or designee, shall train all staff on the requirements of individual physical examination, to include required timelines, as required by 6400.141(a)-(d). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all individual medical records to ensure that individual physical examinations are completed timely and include the information as required by regulation 6400.141(c)(1)-(15), to include physical limitations of the individual. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
11/02/2020
| Implemented |
| 6400.141(c)(13) | Individual #1, date of admission 8/15/2020, had a physical examination on 10/8/19; however, this physical examination did not address allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | An individual physical examination shall include allergies or contraindicated medications. To correct this violation Legacy Service training manual shall include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 141(c)13. This regulation is important as accurate medical information is essential to minimize all health related risks. The CEO updated the organization¿s Medical Management policy and procedures manual to include all proper training and monitoring of physical examinations, to ensure compliance in sections that address allergies or contraindicated medications. The Program Compliance Director will audit all homes medical books for completed physical assessments ensuring they include allergies or contraindicated medications, if applicable. [Immediately, the CEO, or designee, shall train all staff on the requirements of individual physical examination, to include required timelines, as required by 6400.141(a)-(d). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all individual medical records to ensure that individual physical examinations are completed timely and include the information as required by regulation 6400.141(c)(1)-(15), to include allergies and/or contraindicated medications. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
11/05/2020
| Implemented |
| 6400.151(a) | Direct Service Worker #1, date of hire 6/12/2020, does not have a physical examination. Staff person #5, date of hire 6/12/2020, does not have a physical examination. | 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. | To correct the violation a staff person shall have a physical examination within 12 months prior to employment and every 2 years thereafter. This regulation is important because it assures that staff are cleared to meet the physical demands of the job and reduces risk. The Program Compliance Director and CEO training shall include the importance of the regulation to comply with 55 PA Code Chapter 6400 regulation specified in subsection 151(a). The CEO updated the organizations Staffing policy and procedure manuals to include proper monitoring and filing of employee of physicals and TB tests, from date hired and every two years thereafter. CEO will audit files quarterly to ensure newly hired employees receive physicals and TB tests within 24- 48 hours prior to their start date and every 2 years thereafter. [Direct Services Worker #1 had a physical examination dated 6/26/2020, which was verified on 1/10/2021. Direct Services Worker #5 has a physical examination; however, the form is not signed and dated by the physician. Immediately, the CEO, or designee, shall train all staff on the requirements of staff physical examinations, to include required timelines, as required by 6400.151(a)-(c). Documentation of training shall be kept. Immediately, and at least quarterly, for a period of one year, the CEO, or designee, shall audit all staff medical records to ensure that staff physical examinations are completed timely and include the information as required by regulation 6400.151(c)(1)-(3). Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
11/02/2020
| Implemented |
| 6400.181(a) | Individual #1, date of admission 8/15/2020, does not have an initial assessment. Individual #2, date of admission 5/5/2020, does not have an initial assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | An individual shall have an initial functional assessment within 1 year prior to or 60 calendar days after admission to the residential home. An adaptive behavioral assessment and level of skill assessment within 6 months prior to admission. An updated annual assessment is required thereafter. Individual #1 and #2 initial functional assessment completed 10-29-2020. To correct the violation Legacy Residential training and monitoring shall include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 181(a). This regulation is important because Functional Assessments are essential to the Plan of Care development and help to best identify an individual¿s strengths and areas of improvement to aide with the individual meeting personal goals and remaining as independent as possible. The CEO will update the organization¿s Management policy and procedures manual to include all proper training and monitoring of the timely initial and annual Functional assessments. The Program Compliance Director will audit individual¿s books quarterly for completed initial and annual functional assessments. [Individual #1 and Individual #2 had initial assessments completed on 10/29/2020, which were verified on 1/10/2021. Immediately, the CEO shall be trained on the requirements for initial and annual assessments, as required by 6400.181(a)-(f), to include required timelines. Documentation of training shall be kept. As soon as practically possible, the CEO, or designee, shall train all Program Specialist staff, as well as anyone that contributes to the completion of initial and/or annual Individual Assessments, as required by 6400.181(a)-(f), on the requirements of initial and annual assessments, to include required timelines. Documentation of training shall be kept. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all individual files to ensure that initial and annual assessments are completed in their entirety and are completed timely. Documentation of the audits shall be kept. The agency shall develop and implement a tracking system for initial and annual assessments. DPOC by HDKP, HSLS on 1/28/2021]. |
10/29/2020
| Implemented |
| 6400.161(e)(1) | Individual #1, date of admission 8/15/2020, and Individual #2, date of admission 5/5/2020, are self-administering all medications; however, Individual #1 and Individual #2 have not been assessed to be able to recognize and distinguish the individual's medication. | To be considered able to self-administer medications, an individual shall do all of the following: Recognize and distinguish the individual's medication. | To correct this violation individuals will be assessed by direct care staff at the time of medication administration to ensure they are able to recognize and distinguish their medications. Individual #1 and #2 medication assessment completed and documented on 10-28-2020. Legacy Service training and monitoring shall include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 161(e)(1). This regulation is important because reduces medication errors and other potential medication safety risks. The CEO will update the organization¿s Medical Management policy and procedures manual to include all proper training and monitoring of Individual Functional self-administration abilities. The Program Compliance Director will audit medication administration documentation weekly to check for medication errors and ensure compliance. [Individual #1 and Individual #2 were assessed to be able to self-administer medications on 10/28/2020. Immediately, the CEO shall be trained on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. As soon as practically possible, the CEO, or designee, shall train all Program Specialist staff, as well as anyone that contributes to the completion of initial and/or annual Individual Assessments, as required by 6400.181, on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all individual records to ensure that each individual has been assessed for the ability to self-administer medications, to include the ability to recognize and distinguish medications. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
10/28/2020
| Implemented |
| 6400.161(e)(2) | Individual #1, date of admission 8/15/2020, and Individual #2, date of admission 5/5/2020, are self-administering all medications; however, Individual #1 and Individual #2 have not been assessed to be able to know how much medication is to be taken. | To be considered able to self-administer medications, an individual shall do all of the following: Know how much medication is to be taken. | To correct this violation all individuals shall be assessed for recognition and the ability to distinguish how much medication to be taken. Individual #1 and #2 medication assessment completed on 10-28-2020. Legacy Service RN training and monitoring shall include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 161(e)(2). This regulation is important because it provides individuals who administer their own medications with basic assistance in medication management to maximize their independence. The CEO will update the organization¿s Medical Management Program policy and procedures manual to include all proper training and monitoring of Individual medication self-administration abilities. The Program Compliance Director shall audit to assure accurate monitoring of all homes medical program books for completed and verifiable assessment of ability to how much medication to be taken. [Individual #1 and Individual #2 were assessed to be able to self-administer medications on 10/28/2020. Immediately, the CEO shall be trained on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. As soon as practically possible, the CEO, or designee, shall train all Program Specialist staff, as well as anyone that contributes to the completion of initial and/or annual Individual Assessments, as required by 6400.181, on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all individual records to ensure that each individual has been assessed for the ability to self-administer medications, to include knowing how much medication is to be taken. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021.] |
10/28/2020
| Implemented |
| 6400.161(e)(3) | Individual #1, date of admission 8/15/2020, and Individual #2, date of admission 5/5/2020, are self-administering all medications; however, Individual #1 and Individual #2 have not been assessed to be able to know when the medication is to be taken. | To be considered able to self-administer medications, an individual shall do all of the following: Know when the medication is to be taken. Assistance may be provided by staff persons to remind the individual of the schedule and to offer the medication at the prescribed times as specified in subsection (b). | To correct this violation direct care staff will assess and document individual¿s ability to identify proper medication administration times. Individual #1 and #2 have both been assessed for the ability to know when the medication is to be taken 10-27-2020. Legacy Service training and monitoring shall include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 161(e)(3). This regulation is important because it reduces medication errors and possible medical risks. The CEO will update the organization¿s Medical Management policy and procedures manual to include proper training, assessing and documentation of medication administration. The Program Compliance Director will audit to medical files and documentation to ensure compliance. [Individual #1 and Individual #2 were assessed to be able to self-administer medications on 10/28/2020. Immediately, the CEO shall be trained on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. As soon as practically possible, the CEO, or designee, shall train all Program Specialist staff, as well as anyone that contributes to the completion of initial and/or annual Individual Assessments, as required by 6400.181, on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all individual records to ensure that each individual has been assessed for the ability to self-administer medications, to include knowing when the medication is to be taken. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021.] |
10/28/2020
| Implemented |
| 6400.161(e)(4) | Individual #1, date of admission 8/15/2020, and Individual #2, date of admission 5/5/2020, are self-administering all medications; however, Individual #1 and Individual #2 have not been assessed to be able to take or apply the medication with or without assistive technology. | To be considered able to self-administer medications, an individual shall do all of the following: Take or apply the individual's medication with or without the use of assistive technology. | To correct this violation direct care staff will assess and document individual¿s ability to identify proper medication administration times. Individual #1 and #2 have both been assessed for the ability to know when the medication is to be taken 10-27-2020. Legacy Service training and monitoring shall include the importance of the regulation to comply with 55 PA Code 6400 regulations specified in subsection 161(e)(3). This regulation is important because it reduces medication errors and possible medical risks. The CEO will update the organization¿s Medical Management policy and procedures manual to include proper training, assessing and documentation of medication administration. The Program Compliance Director will audit to medical files and documentation to ensure compliance. [Individual #1 and Individual #2 were assessed to be able to self-administer medications on 10/28/2020. Immediately, the CEO shall be trained on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. As soon as practically possible, the CEO, or designee, shall train all Program Specialist staff, as well as anyone that contributes to the completion of initial and/or annual Individual Assessments, as required by 6400.181, on the requirements for individuals to self-administer medications, as required by 6400.161(a)-(e). Documentation of training shall be kept. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all individual records to ensure that each individual has been assessed for the ability to self-administer medications, to include the ability to take or apply medication with or without the use of assistive technology. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 1/28/2021]. |
10/28/2020
| Implemented |
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