| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Criminal background checks were completed outside of the mandatory 5-day timeline for newly hired employees:
Criminal background checks were NOT PROVIDED for the following newly hired employees: staff 2 (DOH 6/28/22), staff 3 (DOH 7/10/22), 4 (DOH 7/18/22), staff 5 (DOH 8/9/22), staff 6 (DOH 8/11/22), staff 7 (DOH 8/31/22), staff 8 (DOH 10/25/22), staff 9 (DOH 11/14/22), staff 10n(DOH 1/11/23) | 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.
| We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.21(a), where criminal background checks for newly hired employees were completed outside of the mandatory 5-day timeline. To correct this issue, We will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Identify all newly hired employees who had criminal background checks completed beyond the 5-day requirement.
b. Review the reasons for the delays in completing the checks and address any internal processes that contributed to the non-compliance.
c. Immediately schedule and expedite the outstanding background checks for affected employees to ensure they are completed within the mandated timeframe.
d. Communicate with relevant staff, including HR and hiring managers, to emphasize the importance of adhering to the 5-day timeline for future hires.
e. Document the progress of completing the delayed background checks and ensure that records are updated accordingly.
f. Provide the Program Director with regular updates on the status of corrections and the completion of background checks. |
09/07/2023
| Implemented |
| 6400.21(b) | The provided employee files did not include verification that an attestation of 2yr PA residency was completed at the time of application, or that an FBI criminal background check was completed if that staff person did not live within the commonwealth for the last two years. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.21(b), where employee files did not include verification of attestation of 2-year PA residency at the time of application or proof of an FBI criminal background check for staff who did not reside within the commonwealth for the last two years. To correct this issue, We will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately identify all employee files that lack the required verification documents related to PA residency and FBI criminal background checks.
b. Contact the affected employees and request the missing documentation, emphasizing the urgency of compliance with regulatory requirements.
c. Review and validate the received documentation to ensure it meets the state's standards and is consistent with the regulations.
d. Complete the necessary forms and verification processes for any outstanding attestation of PA residency or FBI criminal background checks.
e. Ensure that all updated employee files include the required documentation, properly organized and securely stored.
f. Conduct internal audits of employee files to confirm compliance with the regulations and document the corrections made. |
09/07/2023
| Implemented |
| 6400.68(b) | The water temperature in the home is 142.7. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | ¿ The Program Specialist adjusted the water temperature in the home to ensure it is within the safe and regulatory range the day after the inspection.
¿ The Program Director documented the correction of the water temperature, including the date and details of the adjustment and sent a screenshot of the new water temperature to the auditor.
¿ The Program Specialist conducted a thorough inspection of the water heating system to identify any issues that may have caused the excessive temperature.
¿ The Program Specialist addressed and rectify any identified issues with the water heating system to prevent future occurrences of excessive temperatures.
¿ The Program Specialist is the responsible staff member to monitor and maintain the water temperature within the regulatory range. |
09/07/2023
| Implemented |
| 6400.77(b) | There were no tweezers in first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | ¿ Program Specialist procured a pair of tweezers suitable for the first aid kit.
¿ Program Specialist place tweezers in the first aid kit.
¿ Program Specialist conducted a thorough inventory check of the entire first aid kit to ensure no other items are missing or expired.
¿ Program Specialist is the designated staff member for ongoing inventory management.
¿ Program Specialist created and implemented a checklist for documenting inventory checks and restocking activities.
¿ The Program Specialist educated and trained DSPs on maintaining the first aid kit's contents and following the inventory check procedures.
¿ The Program Specialist Implemented a monthly inventory checks and restocking procedures to ensure ongoing compliance. |
09/07/2023
| Implemented |
| 6400.112(b) | Only one sleep drill has been held, but beyond the six-month mark (initial July 2022, sleep April 2023). There is an indication of a drill being held in February 2023 that is marked as "overnight" but it also states that the individual was awake, and the time of the drill was not provided. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.112(b), where only one overnight sleep drill was held beyond the six-month mark, and there is an indication of an overnight drill in February 2023 with incomplete documentation. To correct this issue, We will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Conduct an immediate review of the sleep drill documentation for February 2023 to determine the circumstances and reasons for the drill being marked as "overnight" and the absence of critical details.
b. If the February 2023 drill was intended to be an overnight drill, ensure that it is properly documented with all required information, including the time, duration, and individual's status (awake/asleep).
c. Schedule and conduct a new sleep drill as soon as possible, ensuring it occurs within the required six-month timeframe from the previous drill (before October 2023).
d. Develop and implement clear and standardized procedures for conducting sleep drills, emphasizing the importance of accurate and complete documentation.
e. Provide training to staff responsible for conducting and documenting sleep drills, ensuring they understand the regulatory requirements.
f. Establish a system for tracking and scheduling sleep drills to ensure ongoing compliance with the six-month interval requirement.
g. Maintain comprehensive records of all sleep drills, including documentation of drills conducted and any changes made to improve compliance. |
09/07/2023
| Implemented |
| 6400.141(b) | The individual's 3/16/23 physical form was not signed by the physician for individual 3 | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.141(b), where the physical form for individual 3 dated 3/16/23 was not signed by the physician. To correct this issue, We will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately contact the physician who conducted the physical examination for individual 3 on 3/16/23 to request their signature on the physical form.
b. Follow up with the physician until their signature is obtained on the form, ensuring that all necessary information is properly documented.
c. Review and confirm the completeness of the physical examination form to ensure it meets state regulatory requirements.
d. Ensure that the signed physical form is securely filed in the individual's health records.
e. Develop and implement a systematic process for verifying physician signatures on all physical examination forms before they are added to individual health records.
f. Provide training to staff responsible for collecting and maintaining individual health records to ensure compliance with documentation requirements.
g. Conduct regular audits of health records to verify the presence of physician signatures and address any deficiencies promptly. |
09/07/2023
| Implemented |
| 6400.141(c)(2) | There is no reported immunization history besides COVID vaccine from 2021, and a flu shot from 2020 for individual #3. | The physical examination shall include: A general physical examination. | -The Program Specialist will Review and update physical examination record for individual 1 will review and obtain immunization records if available.
- The Program Specialist will document the completion of the missing immunization information.
- The Program Specialist will schedule individual 3 to complete the missing immunizations. If the individual refuses to be immunized the Program Specialist will document the refusal and create an action plan to encourage Individual 1 to get immunized.
- The Program Specialist was trained on ensuring review and completeness of the Physical Exam form |
09/07/2023
| Implemented |
| 6400.141(c)(6) | There is no indication of a completed TB test for individual #3. | 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. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.141(c)(6), which requires Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older, or an initial chest x-ray with results noted if the Tuberculin skin test is positive. To correct this issue, the provider will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately review the medical records of all affected individuals to identify those who are due for Tuberculin skin testing or chest x-rays based on the regulatory requirements.
b. Contact the individuals' healthcare providers to schedule and perform the necessary Tuberculin skin tests or chest x-rays, ensuring compliance with the required frequency.
c. Ensure that all Tuberculin skin tests and chest x-rays are conducted following the appropriate medical standards and protocols.
d. Document the results of the tests or x-rays in the individuals' medical records, noting whether the results were negative or positive.
e. If any results are positive, follow up with the healthcare provider to initiate appropriate medical interventions and treatments.
f. Develop a tracking system to monitor the timing of future Tuberculin skin tests or chest x-rays for each affected individual and schedule them accordingly.
g. Conduct regular internal audits of medical records to ensure ongoing compliance with Tuberculin skin testing and chest x-ray requirements. |
09/07/2023
| Implemented |
| 6400.141(c)(7) | The last reported Gynecological appointment is from 2020. for individual #3. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.141(c)(7), which requires that individuals receive gynecological appointments at regular intervals. In the case of individual #3, the last reported gynecological appointment is from 2020. To correct this issue, the provider will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Schedule and facilitate an updated gynecological appointment for individual #3 to ensure compliance with the regulatory requirement for regular appointments.
b. Ensure that the gynecological appointment is conducted following established medical standards and protocols.
c. Document the results and recommendations of the appointment in individual #3's medical records.
d. Develop a tracking system to monitor and schedule future gynecological appointments for individual #3 and all other individuals as per regulatory requirements.
e. Conduct regular internal audits of medical records to verify ongoing compliance with gynecological appointment intervals. |
09/07/2023
| Implemented |
| 6400.141(c)(10) | The form did not answer the communicable disease question for individual #3. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | -The Program Specialist updated the physical form free from communicable disease was checked on the physical for individual 1 during the recently conducted Physical.
- The Program Specialist will document any other missing information to ensure completeness of the Physical form.
- The Program Specialist was trained on ensuring review and completeness of the Physical Exam form |
09/07/2023
| Implemented |
| 6400.141(c)(11) | There is no indication of an assessment of the individual's health maintenance needs for individual #3. | 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. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.141(c)(11), which requires an assessment of the individual's health maintenance needs for individual #3, but there is no indication of such an assessment. To correct this issue, we will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately initiate an assessment of individual #3's health maintenance needs, covering all relevant aspects of their physical and mental health.
b. Engage qualified healthcare professionals or specialists as needed to conduct a thorough evaluation of individual #3's health and identify any specific maintenance needs.
c. Document the assessment process, including the goals, findings, and recommendations, in individual #3's health records. |
09/07/2023
| Implemented |
| 6400.141(c)(12) | The form did not answer if the individual has any physical limitations for individual #3. | The physical examination shall include: Physical limitations of the individual. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.141(c)(12), which requires the assessment form to answer if the individual has any physical limitations for individual #3, but there is no indication of such information. To correct this issue, we will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately review the assessment form for individual #3 to ensure that it includes a section specifically addressing physical limitations.
b. Engage the individual and their support team to gather information on any physical limitations that individual #3 may have.
c. Ensure their medical provider document the identified physical limitations, if any, in the assessment form and ensure that it is properly completed. |
09/07/2023
| Implemented |
| 6400.141(c)(13) | The form did not answer if the individual has any contraindicated medications for individual #3. | The physical examination shall include: Allergies or contraindicated medications. | The provider acknowledges the deficiency in compliance with 55 PA Code Chapter 6400.141(c)(13), which requires the assessment form to answer if the individual has any contraindicated medications for individual #3, but there is no indication of such information. To correct this issue, the provider will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately review the assessment form for individual #3 to ensure that it includes a section specifically addressing contraindicated medications.
b. Engage the individual and their healthcare provider to gather information on any contraindicated medications for individual #3.
c. Document any contraindicated medications identified in the assessment form and ensure that it is properly completed.
d. Develop and implement a process to regularly review and update the assessment form to capture any changes in contraindicated medications. |
09/07/2023
| Implemented |
| 6400.141(c)(14) | The form did not answer "medical information pertinent to diagnosis in the event of an emergency." for individual #3. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.141(c)(14), which requires the assessment form to include "medical information pertinent to diagnosis in the event of an emergency" for individual #3, but there is no indication of such information. To correct this issue, we will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately review the assessment form for individual #3 to ensure that it includes a section for documenting "medical information pertinent to diagnosis in the event of an emergency."
b. Engage the individual and their healthcare provider to gather the necessary medical information for emergency diagnosis.
c. Document the pertinent medical information for emergency diagnosis in the assessment form and ensure that it is properly completed. |
09/07/2023
| Implemented |
| 6400.141(c)(15) | The form did not answer special instructions for diet for individual #3. | The physical examination shall include:Special instructions for the individual's diet. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.141(c)(15), which requires the assessment form to include special instructions for diet for individual #3, but there is no indication of such information. To correct this issue, we will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately review the assessment form for individual #3 to ensure that it includes a section for documenting special instructions for diet.
b. Engage the individual and their healthcare provider or dietary specialist to gather the necessary information regarding special dietary instructions.
c. Document the special dietary instructions for individual #3 in the assessment form and ensure that it is properly completed.
d. Develop and implement a process to regularly review and update the assessment form to ensure the accuracy and completeness of special dietary instructions.
e. Conduct training for staff responsible for completing assessment forms to emphasize the importance of including relevant special dietary instructions. |
09/07/2023
| Implemented |
| 6400.142(f) | There is no indication of a written dental plan being completed or included in the individual's information. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.142(f), which requires the completion and inclusion of a written dental plan for individuals, but there is no indication of such a plan for the individual in question. To correct this issue, we will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately initiate the development of a written dental plan for the individual in question, in consultation with a qualified dental professional or specialist.
b. A dental plan was completed for the individual on 09/01/2023. |
09/01/2023
| Implemented |
| 6400.163(a) | 81 mg aspirin located in medication bin unlabeled for individual 3. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.163(a), which requires medications to be labeled properly. In this case, 81 mg aspirin was found in the medication bin unlabeled for individual #3. To correct this issue, we will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately remove the unlabeled 81 mg aspirin from the medication bin.
b. Review the individual #3's medication records and orders to verify the correct medication and dosage.
c. Label the aspirin clearly with the individual's name, medication name, dosage, and any specific administration instructions.
d. Conduct a thorough medication reconciliation to ensure all medications are properly labeled, stored, and administered as per regulatory requirements.
e. Develop and implement a medication labeling policy that outlines the procedures for labeling medications and conducting regular audits to maintain compliance.
f. Train staff responsible for medication administration on the importance of proper labeling and storage of medications.
g. Conduct regular internal audits of medication bins and records to verify compliance with medication labeling standards. |
09/07/2023
| Implemented |
| 6400.163(h) | Medication located in medication bin. Medication does not have a name. medication reads pain 500 mg. this medication is not located on the MAR for individual #3. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.163(h), which requires that all medications be properly labeled and included on the Medication Administration Record (MAR). In this case, medication labeled as "pain 500 mg" was found in the medication bin for individual #3 without proper labeling or inclusion on the MAR. To correct this issue, we will take the following steps, with the responsibility for implementation assigned to the Program Specialist:
a. Immediately remove the unlabeled medication labeled "pain 500 mg" from the medication bin for individual #3.
b. Review individual #3's medication orders and MAR to verify that the medication is not prescribed or documented.
c. Properly dispose of the unlabeled medication in accordance with regulatory guidelines.
d. Conduct a thorough medication reconciliation to ensure that all medications on the MAR match the prescribed medications for individual #3.
e. Develop and implement a medication management policy that emphasizes the importance of proper labeling, documentation, and reconciliation.
f. Train staff responsible for medication administration on the importance of adhering to medication labeling and documentation requirements.
g. Conduct regular internal audits of medication bins, MARs, and medication records to verify compliance with medication management standards. |
09/07/2023
| Implemented |