| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature in the bathroom was 133.7 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The provider immediately turned the water heater down to 110 degrees on April 17, 2024.
The residential director was retrained on 55 PA Code Chapter 6400.68 (b) on April 22, 2024 |
04/17/2024
| Implemented |
| 6400.104 | No notifications were sent to notify the local fire department in writing of individuals needing 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 residential director and Director of Special Projects was retrained on 55 PA Code Chapter 6400.104 on April 22, 2024 |
04/18/2024
| 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. | On May 9, 2024 Individual #1 completed fire safety training with written documentation of completion.
The program director and residential director were retrained 55 PA Code Chapter 6400 on April 22, 2024. |
05/09/2024
| Implemented |
| 6400.181(a) | The initial assessment for individual#1 occurred on 2/13/24, which is greater than 60 days after she started with the provider. | 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 annual assessment on 2/13/2024.
The program director was retrained on 55 PA Code Chapter 6400.181(a) on April 22, 2024 |
02/13/2024
| Implemented |
| 6400.24 | Staff member#1's date of hire 2/15/24, criminal background check not completed until 3/14/24. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The home shall comply with applicable Federal and state statues and regulations and local ordinances
As of 5/1/2024 all current staffs criminal background checks are complete.
The program director was retrained on 55 PA Code Chapter 6400.24 on April 22, 2024 |
05/01/2024
| Implemented |
| 6400.163(d) | There was a bottle of prescription cough syrup unlocked in the kitchen of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.
On April 17, 2024 the prescription cough syrup was placed in the lock box.
The nurse was retrained on 55 PA Code Chapter 6400.163(d) on April 22, 2024. |
04/17/2024
| Implemented |
| 6400.165(b) | Individual#1 was prescribed 50mcg nose spray was not present at site.
Several of the medications prescribed to individual#1 are documented on the MAR and Blister to be taken at 8:00am or 8:00pm, however those times have been shifted to 11:00am and 11:00pm. These medications are as follows:
Lithium Carb 300mg ER: Take 2 tablets by mouth at 8pm
Topiramate Tab 100MG: Take 1 tablet by mouth at 8am and 8pm
Vraylar Cap 3mg: Take one capsule by mouth daily at 8am
Individual#1 is out of Benztropine 0.5mg to be taken in the morning. This medication was not present at site. | A prescription order shall be kept current. | All prescription orders shall be kept current
the nurse was retrained on 55 PA Code chapter 6400.165(b) on April 22, 2024.
The MAR was updated by the pharmacy to reflect the appropriate med times on May 1, 2024
Individual #1's prescription for Benztropine 0.5 Mg was discontinued on 4/16. |
05/01/2024
| Implemented |
| 6400.165(g) | Most recent Psych Review for individual#1 was on 8/14/24, these need to occur every 3 months. | 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 review shall be completed every three months that includes to document the reason for prescribing medication, the need to continue the medication and the necessary dosage.
The program director nurse and behavior specialist were retrained on 55 PA Code Chapter 6400.165 (g) on April 22, 2024.
A request for a psych review was requested on April 18, 2024
expected completion date is 5/30/2024 |
05/30/2024
| Implemented |