| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff number one did not have a Pennsylvania criminal history record check submitted to the State Police before working with individuals. Staff was hired on 12/01/2022 and clearance not submitted until 12/12/2022. | 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 plan is to be more organized because staff 1 actually started work on 12/17/22 and not 12/1/22 |
04/18/2023
| Implemented |
| 6400.67(b) | The filter in dryer located in the basement was full of lint which could cause a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | We have added a sign near the laundry facility that reminds staff to remove the lint after every load has been dried |
04/19/2023
| Implemented |
| 6400.72(a) | The skylight in bathroom #1 did not have a screen or mechanical system. When open to prevent objects to enter. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | A screen has been purchased and installed. |
05/02/2023
| Implemented |
| 6400.72(b) | The screen located on the front screen door is damaged and needs to be replaced or repaired. | Screens, windows and doors shall be in good repair. | The screen has been purchased and installed |
04/19/2023
| Implemented |
| 6400.81(k)(4) | There was no chest or dresser in Individual number #1's bedroom, the clothes are in bags and laundry a basket. | In bedrooms, each individual shall have the following: A chest of drawers. | The dresser has been purchased and installed for individual #1 |
04/28/2023
| Implemented |
| 6400.111(a) | There was no fire extinguisher located in the basement of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Fire extinguisher has been purchased, tagged, and installed in the basement. |
04/19/2023
| Implemented |
| 6400.112(a) | An unannounced fire drill was not held for the month of November 2022. | An unannounced fire drill shall be held at least once a month. | Due to our unorganization the fire drill that was completed in November was not in the correct place to show inspectors at the time of visit. |
04/19/2023
| Implemented |
| 6400.112(d) | The individual was not able to evacuate to a designated area within 2 1/2 minutes for the months of October 2022, September 2022, August 2022, and June 2022. No extended evacuation time from a fire safety expert was provided. | 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. | This house just opened on April the 1st. However, the other house was opened, and it was different management in place during those fire drills. Since we have been under the allotted time for evacuation |
04/19/2023
| Implemented |
| 6400.112(e) | A fire drill was not conducted during sleeping hours at least every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | This location opened on 4/1/2023. Due to our organization issue the fire drill that was completed in November was not in the correct place to show inspectors at the time of visit. We are now organized to show documentation records as outlined in the regulations. |
04/19/2023
| Implemented |
| 6400.113(a) | Individual number one was not trained in fire safety. | 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. | Individual 1 has not been in our care consistently to provide the training. We have updated our policy to ensure that the training is conducted within the first week of admission. The individual is scheduled to be trained on 6/5/2023. |
05/01/2023
| Implemented |
| 6400.141(a) | The agency did not provide a physical for Individual number 1, who was admitted 04/01/2023. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | We have an updated a policy that requires potential admissions to have a complete physical examination. The individual is currently hospitalized and upon discharged has an annual physical examination scheduled to be completed by 6/30/2023. |
04/25/2023
| Implemented |
| 6400.151(a) | Staff number 1, who was hired on 12/01/2022 does not have a physical exam. | 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. | We have updated our policy that requires potential employees to have a physical completed prior to starting with the company. |
04/25/2023
| Implemented |
| 6400.31(b) | Individual number one was not educated in her individual rights. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | We have updated our admission policy which includes that the individual shall be educated on their rights and sign off on a form of understanding. |
04/25/2023
| Implemented |
| 6400.46(b) | The staff and/or individuals at Adolphus was not trained annually by a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | We have reached out to the fire department to schedule a training session/s for staff and individuals. The training is scheduled for 6/5/2023. |
05/01/2023
| Implemented |
| 6400.163(d) | Medication belonging to individual number 1 was found in a bucket and unlocked near the basement steps. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | It is a requirement that unused medication be given back to the pharmacy. We have updated our process that we will take the medication to the pharmacy for disposal instead of waiting for the next delivery. Also, all unused medication is to be locked away out of reach |
04/19/2023
| Implemented |
| 6400.165(b) | A medication record is not being kept for individual number one, which includes the Name of the prescriber, Strength of medication, Dose of medication, Frequency of administration, Date and time of medication administration. | A prescription order shall be kept current. | The MAR was destroyed but now it is the requirement that staff either call/or pick up a new Mar from the pharmacy to stay compliant and also to keep track of medications given. |
04/19/2023
| Implemented |
| 6400.165(c) | The staff that administered the medication for individual number one on 04/17/2023 8am dose, 04/16/2023 8pm dose, 04/15/2023 8am dose, and 04.14.2023 8pm dose did not log, date or initial when medication administration occurred. | A prescription medication shall be administered as prescribed. | The staff was required to complete medication administer training. |
04/25/2023
| Implemented |
| 6400.166(a)(1) | The agency is not utilizing a Medication administration record, medication is listed on a piece of tablet paper for individual number one. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | The MAR was destroyed by the individual, and staff used an improper MAR recording paper. To date the acceptable MARs is being implemented. In addition, it is the requirement that staff either call/or pick up a new Mar from the pharmacy to stay compliant and also to keep track of medications given to prevent future area of noncompliance. |
04/19/2023
| Implemented |
| 6400.169(a) | Staff number one has not completed a department-approved medication administration course, including the annual course renewal requirements. | 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). | Due to our Un organization the documentation could not be located at the time of inspection. The staff had completed the initial training on 1/23/2023. The documentation is now filed correctly for future review. |
04/19/2023
| Implemented |