| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | On 9/17/2021 the exhaust fan in Individual #1's bathroom is inoperable, and there is no other means of ventilation. The exhaust fan in Individual #2's bathroom is inoperable, and there is no other means of ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| To correct the violation, a maintenance request was placed on 9/17/21 9:50 pm via apartment complex maintenance portal to check and fix Individuals #1 and Individuals #2-bathroom fans. Maintenance responded 9/18/21 3:04 pm stating request was completed and Individuals #1 and Individuals #2- bathroom fans are working as expected. |
09/18/2021
| Implemented |
| 6400.81(i) | On 9/17/2021 the blinds in Individual #1's bedroom window were bent. On 9/17/2021 the blinds in Individual #2's bedroom were bent and broken. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | To correct the violation, a maintenance request was placed on 9/17/21 9:50 pm via apartment complex maintenance portal to check and fix Individual #1- and #2-bedroom blinds. Maintenance responded 9/18/21 3:04 pm stating request has been completed. Picture was taking to confirm status of blinds in Individual #1- and #2-bedroom blinds on 9/20/21. [A picture of the new mirror will be sent to the Director on 10/19/21] |
09/18/2021
| Implemented |
| 6400.81(k)(6) | On 9/17/2021 Individual #2 did not have a mirror in their bedroom. | In bedrooms, each individual shall have the following: A mirror. | To correct this action, a new bedroom mirror was purchased for Individual #2¿s bedroom. [A picture of the new mirror will be sent to the Director on 10/19/21] |
10/09/2021
| Implemented |
| 6400.111(e) | On 9/17/2021 the fire extinguisher located in the kitchen is found underneath the sink in a cabinet secured with a child safety lock, thus, preventing the individuals access. | A fire extinguisher shall be accessible to staff persons and individuals. | To correct this action, the Program Specialist immediately removed the child safety lock on the cabinet in the kitchen on 9/17/2021 to comply with 55 PA Code Chapter 6400 regulations specified in subsection 111 (e). (A picture copy is being submitted] |
09/17/2021
| Implemented |
| 6400.113(a) | Individual #1, date of admission 12/02/2020, had fire safety training on 1/31/2021. | 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. | As of 10/9/21, all individuals will be required to complete fire safety training upon admission. |
09/22/2021
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination completed on 1/05/2021 does not include a review of previous medical history. This section was left blank on the form. | The physical examination shall include: A review of previous medical history. | 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). |
10/19/2021
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 12/02/2020 did not have record of a Tuberculin skin testing by Mantoux method. [Repeat violation from 10/27/2020] | 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. | A copy of the physical examination was performed by Alma Illery Medical Department on 12/7/2020 and will be submitted to the Department.
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). |
10/09/2021
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed on 1/05/2021 does not include an assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals. | 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). |
10/09/2021
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination completed on 1/05/2021 does not include physical limitations of the individual. [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). |
10/09/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 1/05/2021 does not include medical information pertinent to diagnosis and treatment in case of an emergency. | 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). |
10/09/2021
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination completed on 1/05/2021 does not include special instructions for the individuals diet. | 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). |
10/09/2021
| Implemented |
| 6400.142(a) | Individual #1 date of admission 12/02/2020 had record of teeth XRAYS dated 8/05/2021. There is no documentation on file that a teeth cleaning or an examination of gums was performed on 8/05/2021. | 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. | 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). |
10/09/2021
| Implemented |
| 6400.144 | Individual #1's physical examination completed on 1/05/2021 included a follow-up recommendation for reflux and constipation. A follow-up did not occur. | 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.
| 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). |
10/09/2021
| Implemented |
| 6400.151(c)(3) | Program Specialist #1's physical examination completed on 11/13/2020 does not address if they are free of communicable diseases. Direct Service Worker #2's physical examination completed on 9/06/2020 does not address if they are 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. | On 9/19/21, the physical examination will 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.
A copy of the updated form will be sent to the Director. |
10/09/2021
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's assessment completed on 1/13/2021 does not include personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | To correct this action, Program Specialist corrected Individual #1¿ss assessment to address current level of performance and progress in personal adjustment. [ A corrected assessment will be sent to the Director} |
10/09/2021
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's assessment completed on 1/13/2021 does not include personal needs with or without assistance from others. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | To correct this action, Program Specialist corrected Individual #1¿s assessment to include current level and progress in personal needs with or without assistance from others. |
10/09/2021
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment completed on 1/13/2021 does not include the individual's need for supervision. | The assessment must include the following information: The individual's need for supervision.
| To correct this action, Program Specialist corrected Individual #1¿s assessment to include individual¿s need for supervision. { A updated copy will be sent to the Director] |
10/09/2021
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment completed on 1/13/2021 does not include the individual's ability to self-administer medications. | 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 individual¿s ability to self-administer medications. |
10/09/2021
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment completed on 1/13/2021 does not include motor skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | To correct this action, Program Specialist corrected Individual #1¿s assessment to include motor skills. [ A copy of the revised assessment which expands the information relative to the individual's progress over the last 365 calendar days. |
10/09/2021
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment completed on 1/13/2021 does not include 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¿s assessment to include individual¿s ability to manage 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 |
| 6400.32(e) | Program Specialist #1 stated Individual #1 is limited on caffeine intake to a couple cans a day with no caffeine after 4 pm each day. There is no physician's order on record for this restriction. | An individual has the right to make choices and accept risks. | To correct this action, the Program Specialist removed the limitation intake of caffeine from Individual 1¿s assessment. Staff were informed that Individual 1 has the right to make a choice about his caffeine intake and accept risks. |
10/09/2021
| Implemented |
| 6400.165(f) | Individual #1 is prescribed Haloperidol to take 1 mg tablet as needed up to 3 times a day for severe psychosis. The 7/08/2021 Individual Support Plan does not include a social, emotional, and environmental plan. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | A written protocol is being considered to address Individual #1¿s social, emotional, and environmental needs related to the symptoms of the individual¿s psychiatric illness. The provider has requested input from the SC. |
10/19/2021
| Implemented |
| 6400.165(g) | Individual #1 is prescribed Haloperidol with instructions to ake 1 mg tablet as needed up to 3 times a day for severe psychosis. There is no record of Individual #1 having a psychiatric medication review. | 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.
Going forward, a hard and electronic copies of all medical records will maintained and filed accordingly. |
10/19/2021
| Implemented |
| 6400.166(a)(8) | The following medications on Individual #1's September 2021 Medication Administration Record did not include the route of administration: Citalopram HBR 20 mg, Famotidine 20 mg, Mirtazapine 15 mg, Prazosin 5 mg, Trazadone 100 mg, and Ciclipirox 0.77% cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Going forward a medical record will be kept, including for each individual for whom a prescription medication is administered: route of administration.
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 6400.166 (a) (8). |
10/09/2021
| Implemented |
| 6400.166(a)(9) | Individual #1's is prescribed Haloperidol 1 mg tablet Take 1 tablet a day as needed for severe psychosis. Individual #1's September 2021 Medication Administration Record did not include the instructions to take up to three times a day, as needed for psychosis. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | As of 10/9/21, a medical record will be maintained to include the following for each individual for who a prescription medication is administered: Frequency of administration.
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 6400.166 (a) (9). |
10/09/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's September 2021 Medication Administration Record did not include the diagnosis or purpose for the following medications: Citalopram HBR 20 mg and Famotidine 20 mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | On 10/19/21, a medical record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pre re nata. |
10/19/2021
| Implemented |
| 6400.169(a) | Direct Care Worker #2 has not successfully completed a Department-approved medication administration course. Program Specialist #1 stated that Direct Care Worker #2 administers medications. | 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). | Going forward, hard copies and electronic copies of completed department approved medication administrative courses will be maintained and filed accordingly.
A copy of the department approved medication administration course will be sent to the Director. |
10/09/2021
| Implemented |