| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The Water temperature in the home was at 159.9. | 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 |
| 6400.141(c)(3) | Immunizations was left blank on the physical for individual 1. | 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. | -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 inidividual 1 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) | The TB testing was left blank on the physical, and no other TB testing was found throughout the medical or program binders. | 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. | -Individual 1 completed their Tuberculin skin testing by Mantoux method with negative results on June 19th, 2023 at the Crozer medical center.
- The Program Director trained the Program Specialist on ensuring review and completeness of the Physical Exam form. |
06/19/2023
| Implemented |
| 6400.141(c)(7) | There was no gynecological exam in the binder for individual 1. | 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. | -Individual 1 completed their gynecological exam testing on June 8th, 2023 at their primary care doctors office.
- The Program Director trained the Program Specialist on ensuring review and completeness of the Physical Exam form during the individuals Physicals.
- If any rejections for any sections, the Program Specialist will come up with an action plan to encourage Individuals to complete their Physicals. |
09/07/2023
| Implemented |
| 6400.141(c)(10) | Free from communicable disease was left unchecked on the physical for individual 1. | 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)(14) | Individual #1 physical left blank information pertinent to diagnoses and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | -The Program Specialist updated the Individual #1 information pertinent to diagnoses and treatment in case of an emergency..
- The Program Specialist will document any other missing information to ensure completeness of the Physical form.
- The Program Director will conduct new staff training on record accuracy and completeness of Physical Examination form. |
09/07/2023
| Implemented |
| 6400.151(a) | There was no physical in the record for Staff 1. | 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 acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.151(a), which states that a physical examination record for Staff 1 was missing from the records.
Staff worked with us for less than 5 days, we reached out to the staff multiple times with no success in getting their Physical form. |
09/07/2023
| Implemented |
| 6400.18(i) | Open incidents for individual 1 are not extended past 30 days. All incidents need to be closed | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | The provider acknowledges the deficiency in compliance with 55 PA Code Chapter 6400.18(i), which requires that open incidents for individual 1 must not be extended past 30 days, and that all incidents need to be closed. To correct this issue, the provider will take the following steps:
a. The Program Specialist will immediately review all open incidents related to individual 1 to identify the reasons for their prolonged status.
b. The Program Specialist is the dedicated staff member responsible for addressing and closing these open incidents promptly.
c. Develop a clear and systematic process for incident resolution, including timelines and responsibilities for staff members involved.
d. The Program Specialist will communicate with relevant staff and external agencies (if necessary) to gather the required information and documentation to close the incidents.
e. The Program Specialist will prioritize the closure of these incidents and ensure that all necessary actions are taken to resolve them effectively.
f. The Program Specialist will regularly monitor the progress of open incidents and track them against established timelines. |
09/07/2023
| Implemented |
| 6400.46(a) | There was no fire safety certificate provided for staff 1. | 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 provider acknowledges the deficiency in compliance with 55 PA Code Chapter 6400.46(a), which mandates that a fire safety certificate must be provided for staff 1, and this certificate was not provided. To correct this issue, the provider will take the following steps:
a. Staff 1 worked for less than 5 shift and did not attend required fire training. This issue cannot be addressed. |
09/07/2023
| Implemented |
| 6400.186 | The program specialist's recommendations were not completed. | The home shall implement the individual plan, including revisions. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.186, where the program specialist's recommendations were not completed. To correct this issue, the provider will take the following steps:
a. The Program Specialist will conduct an immediate and comprehensive review of all recommendations to identify the outstanding tasks and areas of non-compliance.
b. The Program Director will Program Specialist will assign responsibility for each outstanding recommendation to appropriate staff members or teams.
c. The Program Specialist will develop a detailed action plan that outlines the steps required to address each recommendation, including specific timelines for completion.
d. The Program Specialist will communicate with the program director to provide updates on the progress, seek clarification if needed, and collaborate to ensure that recommendations align with best practices and regulatory requirements.
e. The Program Director will monitor and document the progress of each recommendation, ensuring that all necessary actions are taken to fully implement them.
f. The program director will regularly review and update the action plan to reflect the current status of each recommendation and any changes in approach or priorities. |
09/07/2023
| Implemented |
| 6400.186 | Copies of the assessment were sent to the following: was left blank. | The home shall implement the individual plan, including revisions. | We acknowledge the deficiency in compliance with 55 PA Code Chapter 6400.186, where the program specialist's recommendations were not completed. To correct this issue, the provider will take the following steps:
a. The Program Specialist will conduct an immediate and comprehensive review of all recommendations to identify the outstanding tasks and areas of non-compliance.
b. The Program Director will Program Specialist will assign responsibility for each outstanding recommendation to appropriate staff members or teams.
c. The Program Specialist will develop a detailed action plan that outlines the steps required to address each recommendation, including specific timelines for completion.
d. The Program Specialist will communicate with the program director to provide updates on the progress, seek clarification if needed, and collaborate to ensure that recommendations align with best practices and regulatory requirements.
e. The Program Director will monitor and document the progress of each recommendation, ensuring that all necessary actions are taken to fully implement them.
f. The program director will regularly review and update the action plan to reflect the current status of each recommendation and any changes in approach or priorities. |
09/07/2023
| Implemented |