| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | There is no attestation of residency in the state of PA for Staff #1on new employee applications in order to determine if an FBI check should have been completed | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Employees will sign an attestation sheet stating if they have or have not lived in PA for 2 years or more (Attachment #1) |
05/14/2024
| Implemented |
| 6400.62(d) | There was a large container of dishwashing soap stored together with food in a closet in the basement. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Food safety training occurred on 4/8/2024 with staff to ensure the understanding of poisonous materials. (Attachment #3) |
04/08/2024
| Implemented |
| 6400.111(c) | There was no fire extinguisher in the kitchen. The fire extinguisher was located outside of the kitchen door in the dining room area and needs to be moved to the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Fire Extinguisher installed in the kitchen area (Attachment #5). |
03/01/2024
| Implemented |
| 6400.141(a) | The physical for individual #1 is dated 5/18/23 by staff but is signed and dated by the physician 1/24/24. The previous physical in the record is dated 12/13/22 so this exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Uploaded, document from individual number 1 appointment on 5/18/2023 (Attachment#6). Physical was not completed by physician until date of 12/13/22. CHCP staff were trained on doctor appointments and required paperwork to have when attending a physician appointment. (Attachment#7) |
04/01/2024
| Implemented |
| 6400.141(c)(6) | There is no record of individual #1 having a TB test; the most recent physical since admission to the home was on 4/30/23. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual number 1 received TB blood test on 3/12/2024. (Attachment#8) |
04/08/2024
| Implemented |
| 6400.181(a) | Individual #1 was admitted to the home on 4/30/23 and the individual's initial assessment was not completed until 11/2/23. It should have been completed within 60 days, which would have been by 6/29/23. | 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. | Residential director will ensure assessment is completed within 60 days. Program Specialist will audit and send out paperwork to the team within 60 days. New PS is being hired in June 2024. |
06/01/2024
| Implemented |
| 6400.34(a) | Individual #1 was admitted to the home on 4/30/23 and there is no record of individual rights being reviewed with the individual upon admission. There is a form reviewing the option to lock private areas but that was not completed until 11/10/23 and does not include all individual rights. | 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. | Individual Rights was signed by individual number 1 (Attachment #10). |
03/01/2024
| Implemented |
| 6400.165(g) | Individual #1 was admitted to the home on 4/30/23. The prescribed psychotropic medications and the first documented psychiatrist appointment for medication review in the record is 11/30/23. | 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. | Individual admitted to the home 4/30/2024. First Elwyn appointment, |
05/01/2024
| Implemented |
| 6400.166(a)(13) | There were no staff initials for administration of any of individual #1's medications on 2/2/24. There was no documentation on the MAR indicating why medications were not administered on that day. When asked about the absence of initials on the MAR, staff reported that the individual was in the hospital that day. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | CHCP is changing pharmacies and updating the MAR to include a back of the MAR where explanation will be kept. |
06/01/2024
| Implemented |