| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct support staff, 1 hired 1/31/22, did not have a PA state criminal history background check completed within 5 days of hire. An FBI background check was completed only, as this staff resides outside of the state of PA.
Direct support staff, 2 hired 6/30/21, did not have a PA state criminal history background check completed within 5 days of hire. An FBI background check was completed only, as this staff resides outside of the state of PA. | 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 will ensure that all PA state criminal background checks are completed within 5 days of hire. |
05/24/2022
| Implemented |
| 6400.67(a) | The handle had broken off the dryer door and need to be repaired. | Floors, walls, ceilings and other surfaces shall be in good repair. | Door handle has been replaced |
05/24/2022
| Implemented |
| 6400.77(b) | There were no scissors or antiseptic in the first aid kit.[REPEATED NON-COMPLINCE 4/13/21] | 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. | Scissors and antiseptic were replaced |
05/24/2022
| Implemented |
| 6400.106 | There was no annual furnace inspection and cleaning as no verification was provided during inspection. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Ensure the completeness of the furnace inspection within 30 days |
05/24/2022
| Implemented |
| 6400.141(c)(9) | individual 2 did not have an annual prostate exam performed. | The physical examination shall include: A prostate examination for men 40 years of age or older. | A prostate exam has been scheduled and the Annual physical form shall be updated to reflect that it was completed |
05/24/2022
| Implemented |
| 6400.141(c)(10) | individual 2 's 11/1/21 physical states individual is free of communicable diseases, however under diagnosis it states this individual has AIDS. As AIDS is a communicable disease, this form should state he is not free of communicable diseases and list the precautions that must be taken to prevent the 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. | A prostate exam has been scheduled and the Annual physical form shall be updated to reflect that it was completed |
05/24/2022
| Implemented |
| 6400.141(c)(14) | individual's 2 11/1/21 physical did not include information pertinent to diagnosis in case of emergency | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #2 does have pertinent information related to his diagnosis documented on his annual physical form and such information can be found on the form for emergency purposes |
05/24/2022
| Implemented |
| 6400.142(a) | individual 2 did not have an annual dental exam completed. | 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. | Dental exam has been scheduled |
05/24/2022
| Implemented |
| 6400.142(g) | individual 2 did not have an annual dental plan completed. | A dental hygiene plan shall be rewritten at least annually. | A dental appointment has been scheduled and we will ensure that a copy of the dental plan is in our records |
05/24/2022
| Implemented |
| 6400.213(1)(i) | Individual 2 record did not include the date of admission, identifying marks, and primary communication language; the face sheet was updated at inspection to include these things. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The Face Sheet has been updated to include the date of admission, primary communication language (the individual has no identifiable marks and it is N/A) |
05/24/2022
| Implemented |