| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | Individual #1 requires assistance to evacuate the home during a fire. A letter notifying the local fire department of this individual's need for assistance was found within the Individual Record; however, as this letter was not dated, it could not be confirmed that the letter was sent to the fire department upon this individual's admission to the home on 10/16/2024. | 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.
| Upon discovery on the day of inspection, the notification letter was updated with a date of 6/24/25 and was sent to the fire department via certified mail on 6/24.25. The same information was shared with the inspector during the same day of inspection |
06/24/2025
| Implemented |
| 6400.112(c) | The fire drill record for this location's 10/16/2024 overnight fire drill was missing the following required information: the time the fire drill was conducted and the evacuation time for the fire drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Upon discovery, the fire drill of 10/16/24 was updated with the correct times of fire drill and evacuation. This information was found in the fire drill spreadsheet tracker |
06/24/2025
| Implemented |
| 6400.141(c)(10) | Individual #1's Initial Physical Examination, dated 10/10/2024, was missing the following required information: Whether or not the individual was free from communicable diseases. The area of the physical form designated for this information was left blank. | 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. | The physical information form was returned to the PCP and the PCP completed the required section on communicable diseases on 6/30/25. Documentation is attached in a separate email. |
06/30/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's Initial Physical Examination, dated 10/10/2024, was missing the following required information: Medical information pertinent to diagnosis and treatment in case of emergency. The area of the physical form designated for this information was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical exam form was returned to the PCP and the PCP completed the required section on 6/30/25 |
06/30/2025
| Implemented |
| 6400.165(c) | Individual #1 was prescribed Fluticasone Propionate 50mcg Nasal Spray. The administration instructions for this prescription medication on the individual's June 2025 Digital Medication Administration Record (MAR) read: "Instill 2 sprays into both nostrils daily @ 8am (ALLERGIES)." The administration instructions on the pharmacy label attached to the medication's box appeared to have been issued by "Lehigh Valley Health Network Muhlenberg Campus"---a local hospital. Per the Provider, the instructions on this label might have been issued while the individual was being treated at the hospital and sent home with the individual following discharge. This hospital-issued label read: "Frequency: DAILY PRN | Dir: 1 Spray | Route: Each Nare." As the administration instructions on the label and MAR did not match, it was unclear whether this prescription order was being administered as prescribed at the time of each administration.
Individual #1 was prescribed Famotidine 20mg Tablet "Take 1 tablet by mouth daily at bedtime as needed for heartburn/indigestion." Per the June 2025 MAR, this individual was administered one dose of the medication at 8:00pm on 06/16/2025. Upon reviewing the medication blister-pack, it was discovered that only one blister on the medication pack was punctured; a dose of the medication remained adhered within the only punctured blister. As such, despite documentation of administration, there was no evidence that this medication was administered as prescribed on 06/16/2025 at 8:00pm.
Individual #1 was prescribed Micro-Guard 2% Powder "Apply topically to affected area(s) twice daily @ 8am-8pm (ANTIFUNGAL)." The medication the Provider produced when asked for this medication during review was a bottle labeled "Zeasorb AF Antifungal Powder with 2% Miconazole Nitrate." There was a pharmacy label attached to this bottle---once again issued by "Lehigh Valley Health Network Muhlenberg Campus"---that stated that this medication was Miconazole 2% 71g Powder. As neither of the medication names on this bottle matched the medication name on the MAR, evidence shows that the individual was not being administered Micro-Guard 2% Powder as prescribed. | A prescription medication shall be administered as prescribed. | Fluticasone Propionate 50mcg Nasal Spray- that was issued by Lehigh Valley Hospital ER was immediately removed and replaced with PCP prescribed, pharmacy issued Fluticasone Propionate 50mcg Nasal Spray that was present on site.
Famotidine 20mg tablet was already given from a previous blister pack that was already been discarded.
Micro-Guard 2% powder- that was issued by Lehigh Valley hospital- ER was immediately removed and was replaced with a pharmacy labelled/PCP prescribed Micro-Guard 2% powder that was onsite. |
06/25/2025
| Implemented |
| 6400.213(1)(i) | Individual #1's Individual Record was missing the following demographic information: The presence or absence of identifying marks. | Each individual's record must include the following information: Personal information, including: (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | Upon discovery on the same day of inspection, the demographic information was updated to include identifying marks on 6/24/2025. This updated information was shared with inspector on the same day of inspection. |
06/24/2025
| Implemented |