| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #3 was hired on 11/4/2020. Their Pennsylvania State Police Criminal history record check was not requested until 3/4/2021, 4 months after Staff #3's date of hire. This exceeds the requirement. | 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 agency will ensure that each new hire has a PSP Criminal history check within 5 days of date of hire moving forward. |
04/30/2021
| Implemented |
| 6400.82(d) | Located in the basement next to the wall with the washer, dryer, and a sink was a toilet that had no privacy. The agency states no one utilizes that toilet however the toilet would need to have privacy as it is operable. | Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. | The agency has made the toilet inaccessible by blocking with a secured wood encasement as it was not in use and is never used by staff or individuals in the home. |
04/08/2021
| Implemented |
| 6400.112(c) | The 10/13/2020 fire drill record did not record the time of day that the drill occurred. The time section on the form was left blank. | 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. | The agency has revised the Fire Drill form for clarity to ensure each piece of information is recorded for compliance with the regulations. Direct care workers have been informed of the revised fire drill form and have been informed on proper recording for each occurrence. |
04/08/2021
| Implemented |
| 6400.141(a) | Individual #2 had a physical exam completed on 2/12/2020 and their 2021 annual exam was completed on 3/30/21 which
exceeds the annual timeframe. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The agency will ensure that each individual's annual physical examination is conducted in a timely fashion and does not exceed the annual time frame as per regulations. |
04/09/2021
| Implemented |
| 6400.141(c)(1) | The review of previous medical history section was left blank on individual 2's physical exam dated 3/30/21. | The physical examination shall include: A review of previous medical history. | The Agency has revised the Individual's Annual Physical Examination Form for clarity and to ensure compliance with the regulation specific to recording the individual's previous medical history. |
04/09/2021
| Implemented |
| 6400.141(c)(3) | Individual #2's admission physical dated 2/12/2020 and their annual physical dated 3/30/21 did not document their Tetanus/Diphtheria immunization. Corrected at time of inspection as the agency stated that the individual was receiving their Tetanus/Diphtheria on 4/7/21 and provided documentation that it was administered on 4/7/21 | 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. | Corrected at time of inspection as previously noted. The individual received the required immunization on 4/7/21. |
04/07/2021
| Implemented |
| 6400.141(c)(4) | The hearing screening area was not marked on individual 2's physical exam dated 3/30/21. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Direct Care Worker will ensure the medical provider provides each service and documents the same at the time of the appointment. |
04/09/2021
| Implemented |
| 6400.141(c)(12) | The limitation or restrictions of activities area was left blank on individual 2's physical exam dated 3/30/21. | The physical examination shall include: Physical limitations of the individual. | Direct Care Worker will ensure the medical provider provides each service and documents the same at the time of the appointment. |
04/09/2021
| Implemented |
| 6400.141(c)(13) | The contradicted medication area was left blank on Individual 2's physical exam dated 3/30/21. Individual #2's physical exam dated 3/30/21 stated NKA (none known allergies), but their ISP stated they have seasonal allergies their records don't match. | The physical examination shall include: Allergies or contraindicated medications. | Direct Care Worker will ensure the medical provider provides each service and documents the same at the time of the appointment, specifically to include the individual's allergies or contraindicated medications. |
04/09/2021
| Implemented |
| 6400.141(c)(14) | The information pertinent to diagnosis and treatment in case of an emergency area was not marked on individual 2's physical exam dated 3/30/21 | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Direct Care Worker will ensure the medical provider provides each service and documents the same at the time of the appointment, specifically to include the pertinent treatment to an individual in case of an emergency. |
04/09/2021
| Implemented |
| 6400.144 | On 11/24/2020, individual #2 was treated at LVH-17th Street Emergency Department for medication refill, and the discharge instructions to schedule an appointment with LVH-17 Street Mental Health Clinic with a specialty in Psychiatry a soon as possible for a visit. There is no documentation that this occurred. | 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.
| The agency followed up to provide the required regulatory medical services for this individual and according to the directives of this specific medical provider. |
04/09/2021
| Implemented |
| 6400.151(c)(4) | Staff #3's physical exam dated 10/16/2020 did not include or address information of medical problems which might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | The agency Staff Physical Examination form was revised for clarity and to ensure compliance with the regulations. The Staff will utilize the agency form for their Physical Examination at each prescribed occurrence according to the regulations, specifically the medical provider will fill out the response for medical problems which may interfere with the care of the health of the individuals. |
04/09/2021
| Implemented |
| 6400.46(a) | Staff #3 was hired on 11/4/2020 and there is no documentation that they received fire safety training prior to working with individuals. | 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. | The agency has restructured the Staff Training Documentation which the previous Residential Director had failed to record the required staff trainings which were provided but not recorded. This system has been implemented to ensure compliance with the regulations. |
04/09/2021
| Implemented |
| 6400.165(g) | Individual #2 was admitted on 10/13/2020 and is prescribed Sertraline (Depression) and Prazosin (PTSD), and there is no record of them having psychiatric medication reviews. | 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. | The agency has revised the Psychotropic Medication Review form to include response sections for the regulatory requirements, specifically the need to continue the medication, the necessary dosage and the reason for prescribing the medication. |
04/09/2021
| Implemented |
| 6400.166(a)(2) | Individual #2's March and April 2021 Medication Administration Record (MAR) did not list the name of the prescriber for all of their listed prescribed medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The Clinical Manager corrected the MAR to include the name of the prescriber for this individual and each individual throughout the program. |
04/09/2021
| Implemented |
| 6400.166(a)(8) | Individual #2's March and April 2021 Medication Administration Record (MAR) did not list the route of administration for their medication Prazosin 2 mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The Clinical Manager corrected the MAR for individual # 2 to include the route of administration for all medications but specifically for Prazosin 2mg. |
04/09/2021
| Implemented |
| 6400.166(a)(11) | Individual #2's March and April 2021 Medication Administration Record (MAR) did not list the diagnosis or purpose for the following medications: Aripiprazole, Trazadone, and Simethicone. | 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. | The Clinical Manager corrected the MAR for individual # 2 to include the diagnosis for medications; aripiprazole, Trazadone, and Simethicone. |
04/09/2021
| Implemented |
| 6400.182(c) | Individual 1#'s assessment and ISP's supervision do not match. Individual #1's assessment dated 12/20/2020 states that they have no unsupervised time in the home or community due to safety issues and behavioral concerns. Individual #1's ISP supervision needs has not been updated to reflect her current living situation in the community living home and needs. The ISP states that they have alone time both in the home and community.
Individual #1's assessment and ISP for their ability to swim do not match. Individual #1's assessment dated 12/20/2020 skill assessment indicates that they are a 5 which is independent in the ability to swim. Their ISP states Individual #1 does not swim and says they do not know how. The individual plan shall be revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Residential Director has met with the Supports Coordinator to update the information contained within the ISP for accuracy in the individuals current skill set and living arrangement, this was done specific to the following areas; supervision in home and community, and swimming abilities. But all areas were reviewed for other individuals as well for the entire program. |
04/09/2021
| Implemented |