| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self assessments were not completed until 12/11/2020. There is no documentation that there were assessments completed prior to this date. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The new CEO came on board November 19, 2020 and took action regarding compliance. The self assessment was completed, but not within the 3-6 month time frame. To prevent this from happening again, the CEO identified the need for ongoing internal monitoring that shall occur by March 30, 2022, June 2021 and on or before September 2021 which would be three motnhs prior to the annual inspection. The CEO will monitor for progress, areas that require systemic changes and further training. Thereafter, the CEO will initiate the self-assessment process three to six months prior to the annual visit for 2022.
The CEO will send reminders to Administrative staff at least a month before each date listed for them to begin preparations for a review. At the completion of the self-assessments, the CEO will evaluate progress, areas that need to be addressed systemically and provide training. |
03/30/2021
| Implemented |
| 6400.22(d)(1) | Individuals #1 and #2 do not have financial and property records. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A financial and property record has been created for use. Staff from Side B have received information about the form and will be updating the property inventory. Side A will complete the inventory no later than February 1, 2021.
Individual bank accounts were established for both individuals on Side B. Side A has a legal guardian who fills the individual's debit card.
On a monthly basis , the CEO will review the bank statements for Side B.
On Side A, receipts will be attached to the form for the CEO's review monthly. |
01/16/2021
| Implemented |
| 6400.22(e)(3) | Individuals 1 and 2 do not keep receipts for purchases over $15. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Right now we have already implemented a new form to track resources. Each and every time something is purchased, a reason and description of the item and receipts are attached to the form. All receipts will be kept and logged. However, receipts for purchases over $15.00 will be mandatory.
Individual 1 and 2 have opened a new bank account. and have their own debit cards. The bank will also have a record of when and where the card was used. Deposits and receipts are kept in a filing cabinet in the office.
To prevent this from happening again the Program Coordinator has trained all staff in purchasing items for individuals 1 and 2. Program Coordinator will be responsible for maintaining records moving forward. The Program Coordinator/Specialist will print bank statements and show all financial paperwork for the CEO's review monthly. For Side A, the paperwork of receipts will be given to the CEO for review monthly. |
01/01/2021
| Implemented |
| 6400.141(c)(4) | Individual #2 did not have a hearing screening completed for 2020. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | gThe Program Specialist is waiting for an appointment confirmation so the hearing screening can be done. (COVID restrictions made it difficult). Going forward, the Program Coordinator and/or Specialist will ensure that the physical examination form is filled completely..Upon returning to the site with the documentation, the Program Coordinator/Specialist and/or CEO will review the form for compliance. In addition, the CEO is contracting with a Nurse (anticipated February 1, 2021) for consulting and review of medical issues , follow -up and compliance. This will add another layer of oversight that has been lacking. |
02/01/2021
| Implemented |
| 6400.141(c)(13) | Individual #1 physical exam dated 1/24/20 did not contain any list of allergies or lack thereof. | The physical examination shall include: Allergies or contraindicated medications. | Although the Physical form includes allergies and contradicted medications, it was not completed at the time of the examination. Going forward, the Program Coordinator and/or Specialist will ensure that the physical examination form has completed infomraiton about allergies and contradicted medications . The Program Specialist is still trying to schedule an appointment with the doctor. We hope to have this done by Febraruy 15, 2021. When they return with the form, the Program Specialist and/or CEO will review the form for compliance. In addition, the CEO is contracting with a Nurse (anticipated February 1, 2021) for consulting and review of medical issues , follow -up and compliance. This will add additional oversight for compliance. |
02/15/2021
| Implemented |
| 6400.144 | Individual #1 is prescribed Citrucel 500mg as needed and it is on her Medication Administration Record (MAR), however the medication was not present in the home. Individual #1 should have her True Metrix Blood glucose checked daily, as well as True plus safety 28g lancets checked daily and on Dec 11, 2020 there was no signature to reflect this was completed. Individual #2 has instructions on her MAR that reflects True Metrix Blood Glucose test in vitro strips used 2 times daily alternating between premeal and bedtime. On dates 11/8/20; 11/12/20; & 11/15/20 the test were only documented once daily. Individual #2 has True Plus Safety 28 G Lancets to be used 2 times daily, alternating between premeal and bedtime. On dates 11/5/20; 11/8/20; 11/12/20; 11/13/20; 11/29/20; this was only documented once daily. On 11/15/20 glucose was not checked. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The new CEO recognized a need for additional support and assigned a seasoned staff to become the Medication Supervisor. In addition, we are contracting with a Nurse (anticipated date 2/1/21) to consult with us on medical issues, review all medical paperwork for follow-up, recommendations and compliances. While the Medication Supervisor (both locations) will review MAR's for compliance, the Program Specialist /Coordinator must ensure follow-up occurs.
Citrucel has since been discontinued. for Individual #1.
Individual 1 and Individual 2 both get blood sugar checks daily. Because it does not need to be recorded on the MAR, a BSL tracking form was developed to monitor checks. Additionally, staff are to report those checks on the daily log. The Medication Supervisor and/or Nurse will review such documents for compliance.
At the January team meeting, the Program Specialist and/or Medication Supervisor will discuss the MAR and a Medication refresher for staff from Side B. |
01/21/2021
| Implemented |
| 6400.181(e)(6) | Individual #1 assessment stated that poisons are to be locked. Her Individual Support Plan (ISP) states that she is safe with poisons, but they are locked due to the housemate not being safe. Individual #1 ISP also states that she is safe with hygiene supplies and does not use cleaning products. After review of housemate assessment and ISP it reflects that person is safe with poisons. In addition, at the physical site walk through staff informed this licensing representative that both residents were safe with poisons and the poisons were unlocked through out the home. | 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. | The assessment was revised by the Program Coordinator and everything matches according to the individual's needs. The documentation reflects that that poisons are not locked and individual 1 and 2 are safe around chemicals. The ISP has been updated by the Support Coordinator. If there is a change to the Assessment, the Program Coordinator/Specialist will make the necessary edits. If there is a change to be made in the ISP, the Program Coordinator will notify the Supports Coordinator. To avoid this going forward, we will be conducting 3 self-assessments during 2021 to ensure consistency, accuracy and documentation across the board. |
01/14/2021
| Implemented |
| 6400.181(e)(8) | The annual assessment states that Individual 2 can evacuate in the event of a fire, however the self-preservation form that was provided was marked that the individual is not capable of evacuating under 2.5 minutes in the event of a fire without assistance from another individual. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | The Annual Assessment states: Individual #2 is able to exit the house within 2.5 minutes during fire drills and actively participates in fire drills on a monthly basis. She understands the importance of fire drills. However, the wording on the form was confusing. For that reason, the original Self-Preservation form, it is no longer being used and the form has been updated for Individual #2. The CEO developed a form that conforms to licensing and Side B started to use that form for this individual. Going forward, this new form will be completed during each individual's annual review (both locations). |
01/17/2021
| Implemented |
| 6400.211(b)(3) | Individual #2 had no consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| CEO has created a new form that is clear and concise. and will be used for both locations. Program Coordinator/Specialist will use the form and information will be updated during the individual's annual review or any time there is a change in information (both locations). Individual #2 has updated information in the file. |
01/19/2021
| Implemented |
| 6400.18(c) | Emergency contacts are not consistently being notified within 24 hours of the discovery of incidents related to Individual 1 and 2. EIM # 8771811 for Individual #2 was not reported to her emergency contact. EIM #87719217 for Individual 1, no notifications to emergency contacts were made. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | There was no transition when the previous CEO left. As a result, staff did not have access to all parts of HCSIS/EIM. As staff were learning HCSIS/EIM, mistakes were made. That is the case for the reports cited above. Those reports were to be deleted; there was no emergency and family did not need to be notified. However, family notification forms were not used. A form has been developed and whenever there is an incident, the Program Coordinator/Specialist is notifying the family within 24 hours of discovery and we will now have a record of those notifications. |
01/01/2021
| Implemented |
| 6400.18(g) | Investigations are not being implemented with 24 hours of discovery. There was an incident that occurred with Individual 1 where she was choking. EIM # 8606892 for Individual 1 was discovered on 10/5/19 and was documented in a log book and was not reported until a staff read the log book on 10/7/19. It was not reported or investigated until 10/9/19. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | Staff person on shift when the choking incident occurred did not report the incident. Administrative staff noticed the incident when reading over the daily log book and immediately took action.
When the previous CEO left, there was no transition, no one else had access to HCSIS/EIM and we no longer had an internal investigator.
Now we have multiple administrative staff who can report incidents through HCSIS and EIM. A list of reportable incidents is also listed throughout the home. Administrative staff are also going to be Certified Investigators. One has already completed the pre-requisites for the course and two other staff will obtain CI certification by April 2021 as long as they are able to register for the course. The CEO intends to conduct a face-to-face training with Management staff to review incident reporting. This should be completed by February 1, 2021. |
01/27/2021
| Implemented |
| 6400.34(a) | Individual 1 and 2's rights were signed however the rights that were reviewed and signed by the Individual were not current and did not address all of the individual's rights. The rights did not address 32 a, b, c, d, e, f, g, h, I, j, k, p, and q. In addition they did not address 32 t 1-5 and 32 v. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The CEO updated the Individual Rights form to be inclusive of all rights. Program Coordinator or Specialist will inform and explain to the individual(s) and designated guardian, parent or advocate, of the individual's rights and the process to report a rights violation at the annual meetings. To correct this violations, the Program Specialist has reviewed the updated rights with both invidiauls. The policy has also been updated to reflect the corrections and process. |
01/19/2021
| Implemented |
| 6400.46(b) | Staff 2 had fire safety training on 1/21/2019. She didn't have fire safety training again until 9/15/2020, which exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The trainings will be for all staff and will include initial training date as well as expiration of training date so that the training is completed according to regulations. Program Coordinator will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. Additionally, with the self-assessments, any infractions will be caught and corrected prior to the expiration date for the training year. |
01/16/2021
| Implemented |
| 6400.52(c)(1) | Staff 2's annual training did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | CEO has created training for the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. CEO administered the training January 13th and 14th to staff for both locations.
Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
01/14/2021
| Implemented |
| 6400.52(c)(2) | Staff 2's annual training did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Saff have been assigned prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Staff #2 complied with training. training Staff are also reminded about upcoming training/due dates by Relias . Going forward, the training syllabus was updated. Each staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
01/30/2021
| Implemented |
| 6400.52(c)(3) | Staff 2's annual training did not include Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff have been assigned training on Individual Rights through Relias about upcoming due dates. The staff i#2 complied with the training. Going forward, the training syllabus was updated. Each staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
01/30/2021
| Implemented |
| 6400.52(c)(4) | Staff 2's annual training did not include Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Saff have been assigned training on Recognizing and reporting incidents via Relias which also reminds staff of upcoming due dates. Staff #2 complied with training. Going forward, the training syllabus was updated. Each staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
01/30/2021
| Implemented |
| 6400.52(c)(5) | Staff 2's annual training did not include the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff have been assigned training on the Safe and appropriate use of behavior supports via Relias which also reminds staff of upcoming due dates. Staff #2 completed the training. The PCM trainer will provide staff with a refresher during annual training and prior to new staff working with an individual. The training syllabus was updated. Going forward, each staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
01/30/2021
| Implemented |
| 6400.52(c)(6) | Staff 2's annual training did not include implementation of the individual plan | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The Program Specialist will assume responsibility for training staff on individual plans with the support of the PCM trainer and/or Program Coordinator. Identified staff have been trained on the individual plan. Staff #2 was trained on the individual plan.
The training syllabus was updated. Going forward, each staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
01/30/2021
| Implemented |
| 6400.165(b) | Individual #1 is prescribed Acetaminophen 325 tablet to be taken as needed for pain. This medication expired in April 2020. | A prescription order shall be kept current. | Medication was removed and disposed of. The pharmacy was contacted and a new prescription was obtained from the pharmacy . Prescription will be kept current and checked over weekly by the medication supervisor.
Going forward, the newly assigned Medication Supervisor will review medications, the MAR and paperwork for accuracy and compliance. The nurse (anticipated February 1, 2021) who is a consultant will provide an additional layer of oversight. |
12/18/2020
| Implemented |
| 6400.165(g) | Individuals 1 and 2 are prescribed psychotropic medications and did not have medication reviews by a licensed physician 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. | Individuals 1 and 2 are going to the same physician. They both became patients in December. (New patient for Individual #2) (returning patient for individual #1)The appointments will be kept every 3 months to have medication reviews. After an appointment, a follow up will be made for the following 3 months. Program Specialist will keep documentation of any medication changes and doctors notes from the appointments and will share updated information with the Medication Supervisor and Nurse (anticipated February 1, 2021.) The Program Specialist obained a review. for compliance. Going forward, the Medication Supervisor and Nurse will balso e able to review paperwork for compliance |
12/08/2020
| Implemented |
| 6400.166(a)(9) | Individual #2 is prescribed Acetaminophen which reflects on the Medication Administration Record to be given every 6 hours and the pharmacy label on the blister pack reflects that it is to be given every 8 hours as needed. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The CEO identified the need for addtional support and designated a Medicaton Supervisor who will be able to provide another level of review. The nurse (anticipated February 1, 2021) will also provide addtional oversight for compliance. To correct this violation, a correct label was obtained. |
12/18/2020
| Implemented |
| 6400.166(a)(11) | Individual #1 did not have the diagnosis/purpose of the medication for each medication listed on the Medication Administration Record (MAR).Individual #2 medication on the MAR did not reflect the diagnosis or purpose of the prescribed medication. | 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 MARs have been corrected for both individuals. Going forward, a new position was added: Medication Supervisor for both locations. This person will review medications and MARs and doctor orders for consistency and compliance. A nurse is expect to come on board as a consultant (anticipated February 1, 2021) who will provide an additional level of oversight. |
02/01/2021
| Implemented |