| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Criminal check for staff #1 was completed after the allowable time frame of 5 days working with individuals. | 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.
| WHO: CEO
WHAT: An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employee 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.
WHEN: Ongoing |
| Implemented |
| 6400.64(a) | Inside oven door has extensive grease accumulation and needs to be cleaned. | Clean and sanitary conditions shall be maintained in the home. | WHO: Residential Director
WHAT: Clean and sanitary conditions shall be maintained in the home.
WHEN AND HOW: Residential director contracted with a cleaning company to provide deep cleaning of residence. Item was completed on 3rd of April 2021 |
04/03/2021
| Implemented |
| 6400.82(e) | No non slip mat in bathroom. Three flower tub sticks were in tub, but not sufficient enough to cover tub floor. | Bathtubs and showers shall have a nonslip surface or mat. | WHO: Residential Director
WHAT: Bathtubs and showers shall have a nonslip surface or mat.
WHEN AND HOW: Bath mats were purchased and installed on the 26th of march. |
03/26/2021
| Implemented |
| 6400.111(f) | No inspection tag on fire extinguisher near bathroom. Unable to determine if fire extinguisher was inspected | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | WHO: Residential Director
WHAT: A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.
WHEN AND HOW: Provider has contracted with Shapiro Fire protection to complete annual inspections and tagging of fire extinguishers. Inspection and tagging was completed on 8th of APRIL |
04/08/2021
| Implemented |
| 6400.112(e) | Sleeping drills were not provided during inspection. | A fire drill shall be held during sleeping hours at least every 6 months. | WHO: Program Specialist
WHAT: A fire drill shall be held during sleeping hours at least every 6 months.
WHEN AND HOW: A midnight Fire Drill was completed on the 7th of April |
04/07/2021
| Implemented |
| 6400.113(c) | Individual #1 fire safety training was reviewed. It could not be determined what material was covered in the 5/10/20 training. While the agency does have fire safety plans on file for the property, the individual's training record should clearly state what was covered during their training. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | WHO: Program Specialist
WHAT: A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.
WHEN AND HOW. The program specialist has put together a new attestation that reflects the fire safety training mandate and would have Individuals acknowledge administered training. |
04/16/2021
| Implemented |
| 6400.141(a) | It could not be determined that individual #1 had a physical within a year prior to his admission. The physical on file is dated 5/26/20, whereas his admission date is 5/10/20 | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | WHO: Program Specialist
WHAT: An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
WHEN AND HOW: Our Individuals did have appointments within 12 months of admission but the doctors notice was not descriptive and did not reflect key items. We have received a copy of a generic physical form from ODP and would be using same going forward. |
03/26/2021
| Implemented |
| 6400.141(c)(4) | Individual #1 5/26/20 physical is missing the following required information:
· Vision and hearing screenings | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | WHO:Program Specialist
WHAT: The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.
WHEN AND HOW: An annual physical has been scheduled for the resident and the generic annual physical form would be used so that visit captures all that is required per ODP guidelines |
03/26/2021
| Implemented |
| 6400.141(c)(6) | Individual #1 5/26/20 physical is missing the following required information:
· Tuberculosis test, with read date | 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. | WHO:Program Specialist
WHAT: 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.
WHEN AND HOW: An annual physical has been scheduled for the resident and the generic annual physical form would be used so that visit captures all that is required per ODP guidelines |
03/26/2021
| Implemented |
| 6400.141(c)(9) | Individual #1 5/26/20 physical is missing the following required information:
· Prostate exam | The physical examination shall include: A prostate examination for men 40 years of age or older. | WHO:Program Specialist
WHAT: The physical examination shall include: A prostate examination for men 40 years of age or older.
WHEN AND HOW: An annual physical has been scheduled for the resident and the generic annual physical form would be used so that visit captures all that is required per ODP guidelines |
03/26/2021
| Implemented |
| 6400.141(c)(10) | Individual #1 5/26/20 physical is missing the following required information:
· Clearance from communicable disease or, if not cleared, necessary precautions to prevent their spread | 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. | WHO:Program Specialist
WHAT: 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.
WHEN AND HOW: An annual physical has been scheduled for the resident and the generic annual physical form would be used so that visit captures all that is required per ODP guidelines |
03/26/2021
| Implemented |
| 6400.141(c)(12) | Individual #1 5/26/20 physical is missing the following required information:
· Physical limitations | The physical examination shall include: Physical limitations of the individual. | WHO:Program Specialist
WHAT: The physical examination shall include: Physical limitations of the individual.
WHEN AND HOW: An annual physical has been scheduled for the resident and the generic annual physical form would be used so that visit captures all that is required per ODP guidelines |
03/26/2021
| Implemented |
| 6400.141(c)(14) | Individual #1 5/26/20 physical is missing the following required information:
· Medical information pertinent to diagnosis and treatment in case of emergency | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | WHO:Program Specialist
WHAT: The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.
WHEN AND HOW: An annual physical has been scheduled for the resident and the generic annual physical form would be used so that visit captures all that is required per ODP guidelines |
03/26/2021
| Implemented |
| 6400.141(c)(15) | Individual #1 5/26/20 physical is missing the following required information:
· Special diet instructions | The physical examination shall include:Special instructions for the individual's diet. | WHO:Program Specialist
WHAT: The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.
WHEN AND HOW: An annual physical has been scheduled for the resident and the generic annual physical form would be used so that visit captures all that is required per ODP guidelines |
03/26/2021
| Implemented |
| 6400.151(a) | Staff #1 last physical was 11/14/18. A physical must be completed every 2 years. | 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. | WHO: CEO
WHAT: 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.
WHEN AND HOW. Staff has Performed an recent Physical. Item was completed on 4/8/2021 |
04/08/2021
| Implemented |
| 6400.151(c)(2) | Staff #1 last TB was 11/14/18. TB test results not available at time of inspection for Staff #2. | 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. | WHO: CEO
WHAT: 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.
WHEN AND HOW. Staff has Performed an recent Physical. Item was completed on 4/8/2021 |
04/08/2021
| Implemented |
| 6400.151(c)(3) | The physical exams did not indicate if the person was free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | WHO: CEO
WHAT: The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals.
WHEN AND HOW. Staff has Performed a recent Physical using the ODP provided comprehensive form. Item was completed on 4/8/2021 |
04/08/2021
| Implemented |
| 6400.46(a) | Fire safety training not available for staff #1 and #2. | 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. | WHO: CEO?Program specialist
WHAT: 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.
WHEN AND HOW. The program specialist/CEO has put together a new attestation that reflects the fire safety training mandate and would have staff acknowledge administered training. This Item is ongoing |
04/02/2021
| Implemented |
| 6400.50(a) | No record of trainings for any of the staff. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | WHO CEO/PROGRAM SPECIALIST
WHAT: Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.
WHEN AND HOW. While staff have been trained on different items , ISPs, Med admin, Incident management, Conflict management etc, Documentation did not reflect same. Ongoing provider would Collate and properly document records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, This endeavor is ongoing. |
04/09/2021
| Implemented |
| 6400.51(a)(3) | No record of orientation trainings for any of the staff. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | WHO CEO/PROGRAM SPECIALIST
WHAT: Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.
WHEN AND HOW. While staff have been trained on different items , ISPs, Med admin, Incident management, Conflict management etc, Documentation did not reflect same. Ongoing, provider would Collate and properly document records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, This endeavor is ongoing. |
04/09/2021
| Implemented |
| 6400.167(a)(1) | Docostat 100 mg medication not dispensed on March 1, 2, 3. No indication on MAR as why medication was not given. Medication was still in blister packs.
Levothyroxin 88 mg medication not dispensed on March 1, 2, 3. No indication on MAR as why medication was not given. Medication was still in blister packs.
Divalproex 500 mg medication not dispensed on March 1, 2, 3. No indication on MAR as why medication was not given. Medication was still in blister packs. | Medication errors include the following: Failure to administer a medication. | WHO: Program Specialist
What: Going forward, the program specialist would consistently review the MAR and provide training for errant staff. |
06/29/2021
| Implemented |
| 6400.183(c) | It could not be determined that a list of the attendees of individual #1 2020 ISP meeting was kept by the agency. | The list of persons who participated in the individual plan meeting shall be kept. | : WHO: Program Specialist, Residential Director
What: Going forward, the program specialist and Director would ensure that any attendance sheet is be kept on file. |
06/29/2021
| Implemented |
| 6400.213(1)(i) | It could not be determined that the following information is contained in individual #1 file:
· Social Security Number
· Height
· Weight
· Hair color
· Eye color
· Identifying physical marks
· Primary communication language | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | : WHO: Program Specialist
What: Going forward, the program specialist would consistently review the folders of residents and ensure that they include all required data |
06/29/2021
| Implemented |