| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's finances did not have a financial ledger that showed all expense for the individual. The agency had several receipts that were not tracked on the logs. | 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. | The Financial Director is responsible for fixing this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received.
This violation has been implemented on the 14th of October 2024 |
10/14/2024
| Implemented |
| 6400.22(d)(2) | Individual #1's finances did not have a financial ledger that showed all expense for the individual. The agency had several receipts that were not tracked on the logs. | (2) Disbursements made to or for the individual.
| The financial Director is responsible to fix this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received.
This violation has been implemented on the 14th of October 2024 |
10/14/2024
| Implemented |
| 6400.61(a) | Individual #1 has mobility issues and can't independently maneuver steps. The individual's home has a flight of stairs they are required to climb to access all areas of their home. Additionally, the bathtub is difficult for Individual #1 to use in that staff cannot lift the individual's legs over the tub. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | DPOC
The provider will initiate an immediate search for a new accessible residence for Individual #1. The new location will be selected to ensure that Individual #1 can enter and exit the home with minimal assistance, and that there are no steps or obstacles to navigate. Additionally, the provider will ensure that at least one bathroom is fully handicapped accessible. The provider will also ensure that PT/OT evaluations are completed at the new home to ensure that the individual has everything they need to be self-sufficient in their home
The individual and their Supports Coordinator (SC) will visit the prospective home(s) to confirm that the residence meets all of the individual's mobility requirements. The CEO will ensure that only homes which meet these needs are presented to the individual.
The CEO will oversee this process and ensure that the search is completed within 30 days. Regular updates will be provided to the individual, licensing agency, the Supports Coordination Organization (SCO), and the administrative entity.
Should there not be an appropriate home within the provider agency's homes, then a discharge notice will be completed, and the Supports Coordinator will begin the process of finding a new provider that can meet the mobility needs of the individual. The provider will cooperate fully with this transition including providing staff for initial visits. |
02/14/2025
| Not Implemented |
| 6400.64(a) | The front door had vertical stains running down the door ranging in size from 3 feet to 1 foot that resembled dried soda. | Clean and sanitary conditions shall be maintained in the home. | Immediate Actiion! The program manager would arrange to have the door cleaned.
The agency shall ensure that all surfaces are maintained in clean and sanitory conditions.
The program manager on the 10/01/2024 engaged maintenance to clean and paint the door |
10/10/2024
| Implemented |
| 6400.76(a) | There was a small table flipped over in the corner with a broken leg.
The cabinet door above the toaster was off its bottom hinge.
There were 2 broken televisions in the living room with holes in them that could be a hazard. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Program manager would be responsible for this.
Agency shall ensure all furniture and equipment shall be non hazardous, clean and sturdy.
Implementation of this shall be completed 10/14/2024 |
10/14/2024
| Implemented |
| 6400.82(f) | There were no paper or cloth towels for use after handwashing in the bathroom | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The program manager is responsible for making this correction.
A paper towel dispenser plus paper towel would be installed in the bathroom
The dispenser has been installed. Installation date was 10/11/2024 |
10/11/2024
| Implemented |
| 6400.141(c)(10) | Individual #1's most recent physical completed on June 23, 2024, does not document if the individual is free from communicable diseases. | 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 program specialist would be responsible for this correction
The agency would ensure that 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.
Immediate Corrective Actions
1. The Program specialist scheduled a new PCP appointment for the individual so that the medical provider can update individuals annual physical to reflect individuals status.
The program specialist reviewed all current residents' medical records to determine if any individuals with communicable diseases are missing documentation of specific precautions.
All identified records have been updated with the necessary precautions and this will be completed by 10/15/2024.
All physicians providing physical exams for our individuals have been informed of the need to document specific precautions in line with 55 PA Code Chapter 6400.141(c)(10) during their medical examinations of residents. |
10/15/2024
| Implemented |
| 6400.144 | Individual #1 is allergic to Fluticasone and is currently taking Fluticasone.
On May 29, 2024, it was recommended that Gastroenterology be called for Individual #1 no later than June 30, 2024. This did not occur.
Individual #1's Topamax was discontinued on May 29, 2024. Individual #1 was offered the medication on May 29, May 30, 2024, and May 31, 2024 (after the medication was discontinued). The individual refused to take the medication the first two days, but did take the medication on the third day. | 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.
| Program director and program specialist would be in charge of this code
Agency would ensure that 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 agency was able to verify and provide documentation to the effect that the the individual in question was approved to take Fluticasone in the prescribed form. No action was needed but the agency did institute policies to prevent any contravention of the code. |
10/14/2024
| Implemented |
| 6400.171 | At the time of inspection, there was milk with drink by date for 9/3/2024. There was an open bag of French fries in the freezer. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The Program manager would be responsible for this item.
The agency shall ensure food shall be protected from contamination while being stored, prepared, transported and served.
On 09/25/24 the program manager directed that the milk be discarded immediately. The agency has also instituted additional measures to maintain compliance and protection of food. |
09/25/2024
| Implemented |
| 6400.24 | Lorazepam is classified by the DEA as a Schedule IV federally controlled substance Under the 1970 Controlled Substances Act, all class c medications must be double locked and counted at each administration of the medication. This medication was not double locked or counted after each administration. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The program manager and program specialist would be responsible for this.
The agency shall comply with applicable Federal and State statutes and regulations and local ordinances.
Immediate Actions:
daily monitoring, Program specialist has assigned a staff to daily check the Electronic MAR to vify staff are in compliance with regs
Secure Lorazepam in a double-locked cabinet immediately, ensuring compliance with controlled substances regulations.
Implement immediate counting of Lorazepam at each administration, logging the count in a controlled substance tracking sheet. |
09/27/2024
| Implemented |
| 6400.32(g) | According to Individual #1's most recent Individual Plan (ISP), it is strongly desired that Individual #1 be able to watch television. There was no working television in the home.
Individual #1's ISP documents that it makes sense for Individual #1 to be able to spend time in the community. Individual #1 enjoys going to the Dollar Store and clothes shopping. Individual #1 is not taken into the community. | An individual has the right to control the individual's own schedule and activities. | Program manager would be responsible for this code.
The agency would ensure that all individuals has the right to control the individual's own schedule and activities.
Let it be known that individual had only recently damaged the 3rd tv in 4 weeks.
A new tv was immediately purchased and the property manager would be casing the TV with plexiglass to prevent future damage. |
10/16/2024
| Implemented |
| 6400.32(i) | Individual #1 had medications missing and unaccounted for.
On September 2, 2024, the MAR documented that Individual #1 refused their Lorazepam. However, the blister pack was missing this pill. No staff dated or initialed the blister pack that they administered the pill.
The same thing occurred on September 3, 2024, with Individual #1's 8pm dose of Ziprasidone. | An individual has the right of access to and security of the individual's possessions. | The program manager and program specialist would be responsible for this.
The agency shall ensure that all individual have the right of access to and security of the individual's possessions
Immediate Actions:
daily monitoring, Program specialist has assigned a staff to daily check the Electronic MAR to vify staff are in compliance with regs
Secure Lorazepam in a double-locked cabinet immediately, ensuring compliance with controlled substances regulations.
Implement immediate counting of Lorazepam at each administration, logging the count in a controlled substance tracking sheet. |
09/27/2024
| Implemented |
| 6400.32(n) | Individual #1 has the right to have telecommunications with anyone at any time. Their ISP documents that they enjoy making calls to people. During the onsite inspection on September 25, 2024, Individual #1 was crying that they were being held captive in the house and that the provider was not letting the individual call their mom. There was no working telephone in the home for the individual to use. | An individual has the right to unrestricted and private access to telecommunications. | Program manager would be responsible for this code.
The agency would ensure that all individuals has the right to control the individual's own schedule and activities.
Let it be known that individual had damaged the 2nd handset in a 4 week period and the agency had already ordered a new phone prior to the inspection. Receipts were presented to the inspectors.
The phone was promptly installed upon delivery. |
10/14/2024
| Implemented |
| 6400.165(g) | The quarterly psych med review conducted on September 1, 2024, does not have the list of all psychiatric medications, dosages, or reason for taking the meds documented. | 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 program specialist is responsible for this code fix.
The agency would ensure that If a medication is prescribed to treat symptoms of a psychiatric illness, the 90 day review forms would properly and completely reflect such a medication and include the dosage of the medication and reason for the prescription. |
10/17/2024
| Implemented |
| 6400.166(a)(4) | Individual #1 was prescribed Erythromycin on June 26, 2024. The medication was on the MAR, but the medication name was not documented. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The program specialist and medical director would ensure that this code is complied with.
The agency would ensure that a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.
Immediately upon discovery the program specialist
Immediately corrected the MAR by clearly documenting the full name of the prescribed medication, Erythromycin, along with the correct dosage and administration instructions.
The program specialist also Verified the Prescription: Double-check the prescription to ensure the correct medication details are entered. the correction was done on 09/27/2024 |
10/16/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their 8am dose of Fluoxetine on June 21, 29, or 30, 2024.
A new prescription for Topamax was written on June 21, 2024. This medication was never added back on to the MAR or administered.
Individual #1 did not receive their Ziprasidone the entire month of June 2024.
On June 26, 2024, Individual #1 reported they preferred eye drops. Ofloxacin was prescribed. 1 drop was to be administered in the left eye every four hours for 7 days. The medication was only administered 5 days.
Individual #1 was prescribed Budesonide 2 puffs every 12 hours. They did not receive their morning doses on July 27 or 28, 2024, and did not receive their evening doses on July 30 or 31, 2024. They did not receive either dose on July 29 2024.
Individual #1's September MAR documented that Individual #1 did not receive the following 8AM medications on September 20 or 22, 2024:
· Fluoxetine
· Lorazepam
· Montelukast
· Nystatin
· Pantoprazole
· Vitamin B12
· Vitamin B3
· Ziprasidone
· Fluticasone
On September 20, the following medications were not documented as administered to Individual #1, but were not present in the blister packs:
· Fluoxetine
· Lorazepam
· Montelukast
· Pantoprazole
· Vitamin B12
· Vitamin B3
· Ziprasidone
The following 8PM medications were not administered to Individual #1 between September 19, 2024 and September 24, 2024:
· Fluoxetine
· Lorazepam
· Ziprasidone
Individual #1's Lorazepam was not administered on September 16, 2024. The pill was still present in the blister pack. | Medication errors include the following: Failure to administer a medication. | The program manager and medical director are responsible for this code implementation
The agency shall ensure to prevent medication errors include the following: Failure to administer a medication.
The assigned staff stated that the individual declined to take medication but was offered. Staff admitted to failing to document refusal. Agency immediately required staff in question to be administered a practicum training
Agency added a counseling for to the daily progress notes so that staff are able to document efforts to ensure individual takes their medication.
Staff was trained on the need to immediately call a supervisor or behavioural specialist in the event that an individual refuses to take their medication |
10/14/2024
| Implemented |