| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff number 4 was hired November 22, 2022. Criminal history was not completed until December 2, 2022. Criminal history must be completed within five days 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.
| Added statement to the Staff Qualification Policy to say that a background check needs to be completed within 5 working days after the person's date of hire. Created a new hire checklist to ensure that a background check is completed within 5 working days of the date of hire.
The Staff Qualification policy has been updated to include:
¿All new staff are required to submit or obtain a criminal history report within 5 days of hire.
If the staff has been a resident of this Commonwealth for 2 years preceding the date of the request for a criminal history report, the individual shall request a State Police criminal history record.
All new staff are required to submit or obtain a criminal history report has not been a resident of this Commonwealth for the 2 years immediately preceding the date of the request for a criminal history report, the individual will obtain a federal criminal history record.¿ |
05/06/2023
| Implemented |
| 6400.21(a) | No criminal history provided for Staff number 5 | 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.
| A background check was completed for staff number 5 on date. The program director will review records to ensure that a background check is completed for all employees. The CEO will complete background checks for all new employees within 5 working days of hire. The New Employee Checklist will be used to review the employee file to ensure that background checks have been completed within 5 days of hire by the end of the orientation process before new staff work with any participant at SLT. The New Hire Checklist will be a part of the new hire orientation process to ensure compliance. All staff will be trained on the New Hire Checklist. *See attached New Hire Checklist |
06/05/2023
| Implemented |
| 6400.112(a) | No fire drill for the month of December | An unannounced fire drill shall be held at least once a month. | Re-train all staff on the fire drill policy by 6-5-23. Moving forward, the house manager will complete a monthly check that will include a response for the monthly fire drill. The house manager's monthly check form will be turned into the program director monthly to ensure the fire drill compliance. The program director will review the monthly document to ensure that the monthly fire drill is complete. If anything on the form isn't in compliance the program director will follow up the house manager to assist in correcting the issue by the 15th of the following month. |
06/05/2023
| Implemented |
| 6400.112(d) | Fire drill for November 2022 does not indicate length of time for evacuation. Only the time pf day is indicated | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Plan of correction: Staff will be retrained on the Fire Drill Policy by 6-5-23. There is a House Manager Monthly Form that will ensure that all requirements are met to ensure fire drill compliance. House manager will be trained on the house manager monthly form by 6-5-23. Forms will be turned in to the program director by the 30th of each month. The program director will review all forms to ensure that they are done and complete and respond to any error by the 15th of the following month. |
06/05/2023
| Implemented |
| 6400.142(a) | No dental exam for individual number 1 | 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. | Plan of correction: Dental appointment for individual #1 has been scheduled for date. The house manager monthly check form has a prompt for the house manager to review medical appointments and schedule upcoming appointments to ensure compliance. The house manager will be trained on the managers monthly check form by 6-5-23. This information will be submitted to the program director for review by the 30th of each month for review to ensure compliance. If anything on the form isn¿t in compliance the program director will follow up the house manager to assist in correcting the issue by the 15th of the following month. |
06/05/2023
| Implemented |
| 6400.144 | There are several mismatches between Individual 1 MAR and the prescription orders listed on the pharmacy labels of their medication. The MAR inaccurately lists the dosage of their fluticasone nasal spray, with the medication packaging listing 50 mcg. but the MAR listing 50 mg., a substantial difference. Other entries on the MAR do not capture full details from the pharmacy labels as well---for example, the individual's Risperidone pharmacy label indicates it should be taken at 9PM but the MAR tracks an 8PM administration, and the MAR often truncates the full written order, often omitting details such as route of administration. (For example, their Divalproex Sodium indicates 2 tablets should be taken by mouth at bedtime; the MAR only states "Take 2 Tablets" on the 8PM administration line.) MAR listings and pharmacy labels must match. | 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.
| Plan of correction: Staff will be retrained in the medication administration process by 6/5/23. There will be a med check sign and 5 rights signs posted inside the medication closet to remind staff to slow down when giving medications and check the 5 rights to ensure accuracy. A medication audit form must be completed each time medications are given to ensure that all areas of medication administration are followed. The form also prompts the reviewer to write an incident report for all medication errors. |
06/05/2023
| Implemented |
| 6400.151(a) | No physical provided for staff number 5.
There is no physical for staff person number 2.
Staff number 3 was hired on November 28, 2022. Physical exam was not completed until January 3, 2023 | 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. | Plan of Correction: All staff are required to submit a complete physical before they work with any individual supported by SLT. Staff # 2 and 5 will submit a complete physical by 6/5/23. Staff #3 need to complete a PPD test by 6/5/23. |
06/05/2023
| Implemented |
| 6400.151(c)(2) | There is no read date for the TB test for Staff 1. There is a date when the test was administered May 27, 2022. There is a negative result only. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff #1 need to complete a full PPD test by 6/5/23. The new employee checklist has a space to document the date that the PPD was administered and results read to ensure compliance. The program director will supervise the completion to ensure that all tasks are completed by 6/5/23. |
06/05/2023
| Implemented |