| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 7/13/21 at 12:45 PM there was no lighting in the outside area leading from the door in the room to the right of the kitchen to the back yard. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 1. Provider will install motion censored lights outside of back door and front door at The home.
2. Provider will test and ensure the lights installed are operable upon installation.
3. On July 26, 2021 Provider purchased 3 motion censored lights
4. On August 1, 2021 provider will install the 3 motion censored lights. |
08/09/2021
| Implemented |
| 6400.110(e) | On 7/13/21 at 12:55 PM the smoke detectors located on the basement level, first floor, and second floor were not interconnected. | 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. | 1. Interconnected firealarms have been installed at the home on 7.21.2021 by ABC Fire.
2. Interconnected fire alarms were installed on basement level, first floor and second floor. |
08/01/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination, completed 8/25/2020, did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 1. An updated agency physical form has been completed to include:
a. Vision Screening
b. Hearing Screening
2. Individual # 1 has an appointment scheduled with Dr. 7/30/2021. Provider will have Physician complete updated Physical paper work.
3. Updated physical paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination, completed 8/25/2020, did not address communicable disease. | 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. | 1. An updated agency physical form has been completed to include:
a. Free of Communicable Diseases
2. Individual # 1 has an appointment scheduled with Dr. 7/30/2021. Provider will have Physician complete updated Physical paper work.
3. Updated physical paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 8/25/2020, did not address health maintenance needs. | 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. | 1. An updated agency physical form has been completed to include:
a. Health Maintenance needs
2. Individual # 1 has an appointment scheduled with Dr. 7/30/2021. Provider will have Physician complete updated Physical paper work.
3. Updated physical paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination, completed 8/25/2020, did not address allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | 1. An updated agency physical form has been completed to include:
a. Allergies
b. Contraindicted medications
2. Individual # 1 has an appointment scheduled with Dr. 7/30/2021. Provider will have Physician complete updated Physical paper work.
3. Updated physical paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 8/25/2020, did not address medical 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. | 1. An updated agency physical form has been completed to include:
a. medical information pertinent to diagnosis in case of emergency
2. Individual # 1 has an appointment scheduled with Dr. 7/30/2021. Provider will have Physician complete updated Physical paper work.
3. Updated physical paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.151(a) | Program Specialist #3, date of hire 3/5/2021, did not have a physical examination. | 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. | 1. Program Specialist #3 Obtained her Physical 7.15.2021 on the Company required physical form.
2. Program Specialist # 3 and all off staff have been trained on the requirements of 55 PA Code Chapter 6400.151(a) . |
08/01/2021
| Implemented |
| 6400.151(c)(3) | Direct Service Worker #1's physical examination completed 4/12/2021 does not address if staff is free from communicable disease. Direct Service Worker #2's physical examination completed 2/27/2021 does not address if staff is free from communicable disease. | 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. | 1. Direct Service Worker # 1 Provider who completed Physical has been contacted, an updated form has been sent to CRNP, for completion.
2. Direct Service Worker # 2 Has been provided a company Physical examination form to take to his provider to update and complete in its entirety. |
08/09/2021
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment, completed 4/28/2021, did not address the ability to safely use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | 1. An updated Assessment form has been completed to include:
a. The individuals ability to safely use or avoid poisonous materials.
2. Program Specialist has completed an updated Assessment to include:
a. The individuals ability to safely use or avoid poisonous materials.
3. Updated Assessment paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.181(e)(7) | Individual #1's assessment, completed 4/28/2021, did not address knowledge of the danger of heat sources and ability to move away from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | 1. An updated Assessment form has been completed to include:
a. The individuals ability to acknowledge the danger of heat sources and the ability to move away from heat sources.
2. Program Specialist has completed an updated Assessment to include:
a. The individuals ability to acknowledge the danger of heat sources and the ability to move away from heat sources.
3. Updated Assessment paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.181(e)(8) | Individual #1's assessment, completed 4/28/2021, did not address the ability to evacuate in case of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | 1. An updated Assessment form has been completed to include:
a. The individuals ability to evacuate in case of a fire
2. Program Specialist has completed an updated Assessment to include:
a. The individuals ability to evacuate in case of a fire
3. Updated Assessment paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment, completed 4/28/2021, did not address the knowledge of water safety and ability to swim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | 1. An updated Assessment form has been completed to include:
a. The individuals knowledge of water safety and ability to swim.
2. Program Specialist has completed an updated Assessment to include:
a. The individuals knowledge of water safety and ability to swim.
3. Updated Assessment paperwork will be placed in individual # 1 records |
08/09/2021
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Vitamin D-3 1,000 unit soft gel, take 1 capsule by mouth twice a day. The Medication Administration Record for July 2021 states that Individual #1 should be administered Vit D3 50 MCG (2000 unit), take 2 tablets (4,000 units) by mouth daily. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | 1. An updated Medication Administration Record has been completed to reflect the correct dosage prescribed by the Physician
2. The individual is to be prescribed Vitamin D-3 1,000 units soft gel take one capsule by mouth twice daily.
3. All staff have been trained on 55 PA Code Chapter 6400.166(a)(6) requirements : dosage form |
08/01/2021
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Vitamin D-3 1,000 unit soft gel, take 1 capsule by mouth twice a day. The Medication Administration Record for July 2021 states that Individual #1 should be administered Vit D3 50 MCG (2000 unit), take 2 tablets (4,000 units) by mouth daily. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | 1. An updated Medication Administration Record has been completed to reflect the changes made by the Physician.
2. The individual is to be prescribed Vitamin D-3 1,000 units soft gel take one capsule by mouth twice daily.
3. All staff have been trained on 55 PA Code Chapter 6400.166(a)(6) requirements |
08/01/2021
| Implemented |
| 6400.166(a)(11) | The medication administration record for July 2021 for Individual #1 does not list the diagnosis or purpose for the prescribed Divalproex, Vitamin D-3, Levothyroxine, Quetiapine, Risperidone, and Propranolol. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 1. An updated Medication Administration Record has been completed to include the individuals diagnosis.
2. The updated MAR has been implemented effective July 15, 2021. |
08/01/2021
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Divalproex DR 500 MG, take 1 tablet by mouth three times a day. The prescribed medication was not recorded in the medication record at the time the medication was administered on 7/8/2021 at 5:00 PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | 1. All residential staff have received training on completion and accuracy of the MAR to include the following:
a. No pre-signing of the MAR
b. All meds provided must be noted at the time of Administration
c. Any missing entries must be reported to Management ASAP.
2. The missing entry has been updated with the correct MAR entry
3. DSP # 3 was immediately trained on the MAR requirements with the following:
a. No pre-signing of the MAR
b. All meds provided must be noted at the time of Administration
c. Any missing entries must be reported to Management ASAP. |
08/01/2021
| Implemented |
| 6400.169(a) | Program Specialist #3 administered medications to individual #1 on 3/12/2021 -- 3/14/2021 and on 3/19/2021 -- 3/21/2021 at 9:00pm without successfully completing the Department-approved medication administration course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | 1. Effective immediately Program specialist #3 is not permitted to administer medications.
2. Program specialist has enrolled in a Medication Administration Training. The training is July 27 & July 28. Upon completion of training and monitored medication passes Program Specialist #3 will be trained in Medication Administration.
3. Upon completion of Medication Administration Training Program Specialist #3 must provide iHomecare Solutions with all necessary documents certifying that she is trained by a state of Pennsylvania approved Medication Administration Program. |
08/09/2021
| Implemented |