| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The home did not notify the local fire department in writing of the address of the home and exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| On April 18, 2024 the home notified the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification is current
The residential director was retrained on 55 PA Code Chapter 6400.104 on April 22, 2024 |
04/18/2024
| Implemented |
| 6400.110(e) | The smoke detectors in the home are not interconnected. They are present on all 3 floors and work independently of each other. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | On April 26, 2024 a new smoke detector system was installed. They are present on all three floors and are interconnected
The residential director was retrained on 55 PA Code Chapter 6400.110 (e) on April 22, 2024 |
04/26/2024
| Implemented |
| 6400.112(d) | Multiple fire drills were conducted that were over 2 1/2 minutes long. No extended evacuation times were granted, and no documentation found from a fire safety expert in writing at the time of the inspection. | 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. | On 5/9/2024 Individual #1 received fire safety training.
The program director was retrained on 55 PA Code Chapter 6400.112(d) on April 22, 2024
A fire drill was conducted on April 18, 2024. Individual #1 was able to evacuate in 2 minutes. |
05/09/2024
| Implemented |
| 6400.112(e) | There were no fire drills conducted during sleeping hours at this location at least every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | On April 19, 2024 an overnight fire drill was conducted at 2:00 AM |
04/19/2024
| Implemented |
| 6400.113(c) | Individual#1 had fire safety training shortly after admission, however the agency does not have documentation that this occurred. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Individual #1 completed fire safety training on 5/9/2024
As of 5/9/2024 A written record of fire safety training including the content of the training and a list of the individuals attending is kept.
The program director was retrained on 55 PA Code Chapter 6400 on April 22, 2024. |
05/09/2024
| Implemented |
| 6400.141(a) | Individual#1 had a PCP appointment on 4/3/24, however this appointment did not contain the items outlined in the RCG. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 received an annual physical on 4/3/2024.
Individual # 1's PCP provided the home with the appropriate annual physical examination form on 4/23/2024.
Individuals shall have a physical examination within 12 months prior to admission and annually thereafter.
The program director was retrained on 55 PA Code Chapter 6400.141(a) on April 22, 2024 |
04/23/2024
| Implemented |
| 6400.151(a) | Staff#1 did not have a physical exam completed in the record at inspection. | 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. | As of 5/1/2024 All current staff members have a physical exam on file.
All staff that comes into direct contact with the individuals shall have a physical exam within 12 months prior to employment and every 2 years thereafter.
The program director was retrained on 55 PA Code Chapter 6400.151 (a) on April 22, 2024 |
05/01/2024
| Implemented |
| 6400.151(c)(2) | There was no Tuberculin skin test by Mantoux method with negative results every 2 years found in the record at time of inspection for Staff Member 1. | 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. | As of May 1, 2024 - All current staff have Tuberculin Skin test with negative results on file.
The program director was retrained on PA Code Chapter 6400.151 (c)(2) |
05/01/2024
| Implemented |
| 6400.181(a) | Assessment for individual#1 was completed on February 13, 2024, however this is greater than 60 days after being admitted into the agency. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual # 1 received an initial assessment on 2/13/2024.
The program director was retrained on 55 PA Code 6400.181 on April 22, 2024. |
04/22/2024
| Implemented |
| 6400.24 | Staff#1 self-attestation on application lists the staff member as not residing in pa 2 years prior to employment, however, no FBI background check was completed for this staff member. Additionally, the 1970 Controlled Substances Act requires pill counts to be kept for controlled substances, and for controlled substances to be double-locked. Individual#1 is prescribed Clobazan 10mg. This medication is a controlled substance and one of the blister packs is counted, however she had a second blister pack with 2 tablets that was single locked and not counted. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Staff #1 resigned from the home as of April 18, 2024.
As of 5/1/2024 all staff have the appropriate criminal history checks on file.
Individual #1's Clobazan 10 mg is counted and double locked.
The program director was retrained on 55 PA Code Chapter 6400.24 on April 22, 2024
The nurse was retrained on 55 PA Code Chapter 6400.24 on April 22, 2024 |
05/01/2024
| Implemented |
| 6400.165(b) | Individual#1 is prescribed Mucinex 600mg PRN which is not present in the home. | A prescription order shall be kept current. | As of 4/30/2024 a prescription for Mucinex 600 MG is present in the home for individual #1
The nurse was retrained on 55 PA Code Chapter 6400 on April 22, 2024. |
04/30/2024
| Implemented |
| 6400.165(g) | Individual#1 does not have any completed psychiatric medication reviews on file. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A request for the completion of a psychiatric medication was requested for individual #1 on April 18, 2024.
The nurse and behavior specialist was retrained on 55 PA Code Chapter 6400.165(g) on April 22, 2024 |
05/30/2024
| Implemented |