| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #2 was hired on 12/05/2023 and a Pennsylvania criminal history record check was not completed until 2/28/2024, more than two months after the staff was hired and began 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.
| The issue with Staff #2¿s Pennsylvania criminal history record check has been resolved, with the check completed on 2/28/2024 |
07/24/2024
| Implemented |
| 6400.141(c)(11) | The annual physical examination completed on 1/08/2024 for Individual #1 did not include documentation of the health maintenance needs of the individual. (There was a line for this with yes/no checkmarks -- yes was checked but there was no additional information or instruction for 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. | The annual physical examination for Individual #1 lacking an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals has been corrected by having the physical form filled out by the primary care doctor and the above missing information was included |
08/26/2024
| Implemented |
| 6400.141(c)(14) | The annual physical examination completed on 1/08/2024 for Individual #1 did not include documentation of 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. | The annual physical examination for Individual #1 lacking Medical information pertinent to diagnosis and treatment in case of an emergency has been corrected by having the physical form filled out by the primary care doctor and including any missing information |
08/26/2024
| Implemented |
| 6400.141(c)(15) | The annual physical examination completed on 1/08/2024 for Individual #1 did not include documentation of the individual's recommended diet or special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | The annual physical examination for Individual #1 lacking documentation of the recommended diet and special dietary instructions has been corrected by having the physical form filled out by the primary care doctor and including any missing information |
08/26/2024
| Implemented |
| 6400.142(f) | Individual #1 did not have a dental hygiene plan in their record. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The issue of Individual #1 lacking a dental hygiene plan in their record has been corrected, with a comprehensive dental hygiene plan now documented and included in their file by the clinical director |
08/11/2024
| Implemented |
| 6400.151(a) | Staff #2 did not complete a physical examination within 12 months prior to the date of hire. Staff #2 was hired on 12/05/2023 and did not complete a physical examination until 1/24/2024. | 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. | The issue regarding Staff #2¿s physical examination has been corrected, with the examination completed on 1/24/2024. |
07/24/2024
| Implemented |
| 6400.151(b) | The physical examination that Staff #3 completed on 3/03/2024 (date of hire 4/08/2024) was not signed or dated by the medical provider. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff #3's physical examination form was returned, to the medical provider for proper signing and dating, ensuring the document is fully validated. |
08/05/2024
| Implemented |
| 6400.181(e)(4) | The initial assessment completed on 2/24/2024 for Individual #1 did not contain documentation of the individual's supervision needs, required staff ratios, level of supervision necessary (i.e. eye sight range, same room, etc.) and frequency of checks when the individual is alone in their bedroom. The information that is contained in the assessment regarding supervision is very vague and provides no guidance regarding the individual's 2:1 staffing needs. Individual #1 is currently being staffed at a 2:1 level "for safety" but there is no specific information in the document identifying whose safety and/or safety from what is required. The assessment states that the individual can have "safely unsupervised time in the home" and that the individual "can be in his room alone with staff regularly checking in" on the individual, but the assessment does not specify how frequently staff should conduct those checks. The assessment states that the individual "may remain on the property alone with staff on the premises" but does not specify where staff should be in relation to the individual. | The assessment must include the following information: The individual's need for supervision.
| The initial assessment for Individual #1 was revised immediately to include detailed documentation of the individual's specific supervision needs, including the required staff ratios, levels of supervision necessary (e.g., eyesight range, same room), and the exact frequency of checks when the individual is alone in their bedroom has been updated to every 15 minutes. The assessment also clarified the reason for the 2:1 staffing, specifying whose safety is being addressed and from what risks. |
08/01/2024
| Implemented |
| 6400.181(e)(9) | The initial assessment completed on 2/24/2024 for Individual #1 did not contain documentation of the individual's disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The initial assessment for Individual #1 will be updated immediately to include comprehensive documentation of the individual's disability, covering both functional and medical limitations. The assessment will be reviewed with the clinical director, to ensure accuracy and completeness. Moving forward, all initial assessments will be carefully reviewed for thorough documentation of all required details, including disability-related information, before being finalized. Staff involved in completing assessments will receive additional training on the importance of fully documenting these aspects. As a preventative measure, a checklist will be implemented to ensure that all required elements are included in each assessment, and regular audits will be conducted to verify compliance. |
08/26/2024
| Implemented |
| 6400.32(v) | The individual rights statement reviewed with and signed on 1/05/2024 did not include: an individual's rights may only be modified to the extent necessary to mitigate a significant health or safety risk to the individual or others. | An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | To correct this, the individual rights statement for the document signed on 1/05/2024 will be revised to include the language stating that an individual's rights may only be modified to mitigate a significant health or safety risk to the individual or others. |
07/31/2024
| Implemented |
| 6400.51(b)(4) | There was no documentation that Staff #1 (date of hire 11/30/2023) and Staff #3 (date of hire 4/08/2024) completed training in recognizing and reporting incidents as a required part of orientation training. | The orientation must encompass the following areas: recognizing and reporting incidents. | Both staff #1 and #3 had completed the Relias training on Writing incident reports which did not meet regulatory requirements. Both staff had ODP trainings on Recognizing and Reporting Incidents completed on December 14th and March 12th respectively |
08/01/2024
| Implemented |
| 6400.165(g) | Individual #1 had a review of psychiatric medication on 5/08/2024 and the record of the visit did not document the reason for prescribing the medication, the need to continue the medication and the necessary dosage of the medication. | 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. | The psychiatric medication review record for Individual #1 was be updated to include the reason for prescribing the medication, the need to continue it, and the necessary dosage. The psychiatrist was contacted to provide the missing details. |
08/28/2024
| Implemented |
| 6400.166(a)(9) | The medication administration record (MAR) for Individual #1 did not record a frequency of administration for the pro re nata (PRN) medication polyethylene glycol 3350 powder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The medication administration record (MAR) for Individual #1 was be updated immediately to include the frequency of administration for the PRN medication, polyethylene glycol 3350 powder. |
08/26/2024
| Implemented |
| 6400.166(a)(11) | The medication administration record (MAR) for Individual #1 did not record a diagnosis or purpose for the pro re nata (PRN) medication polyethylene glycol 3350 powder. | 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. | The medication administration record (MAR) for Individual #1 will be updated immediately to include the diagnosis and purpose for the PRN medication, polyethylene glycol 3350 powder. |
08/26/2024
| Implemented |