| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | No criminal history check found in the record for staff 3. | 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.
| Human Resource Manager will complete a background check for all new employees prior to start date. |
12/01/2024
| Implemented |
| 6400.21(b) | No PA attestation found. FBI criminal check should have been performed for staff 4, and staff 5. | 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.
| Human Resource Manager will include PA attestation as a part of new employee documentation; requiring all new hires to submit with application. All prospective employees that do not meet the regulation will be required to have an FBI background check. |
12/01/2024
| Implemented |
| 6400.72(a) | A screen is missing from the window in Individual 1's room. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Maintenance will install screen in individual 1's bedroom |
12/01/2024
| Implemented |
| 6400.81(k)(6) | There is no mirror in Individual 1's room. | In bedrooms, each individual shall have the following: A mirror. | Maintenance will install mirror in individual 1 room |
12/01/2024
| Implemented |
| 6400.104 | The fire department notice did not include specific information about the locations of the individuals' bedrooms. | 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.
| The Director of Operations will amend the fire department notice to include the location(s) of the individuals bedrooms |
12/01/2024
| Implemented |
| 6400.106 | The provided furnace documentation were proposals for service only and not invoices or receipts for completed work. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Director of Operations will obtain written documentation of professional furnace cleaning |
12/01/2024
| Implemented |
| 6400.112(c) | The time of the 12/14/23 fire drill, and the designated meeting place, were not entered on the drill form. | 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. | The Coordinator of Training and Compliance will review the Fire Drill Regulations with the House Manager to assure understanding of expectation and compliance |
12/01/2024
| Implemented |
| 6400.112(d) | The 11/16/23 fire drill completion time is written at 2.5 making it impossible to ascertain if the drill was completed in 2m 50s or 2m 30s. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | The Coordinator of Training and Compliance will review Fire Drill regulations with house manager to confirm understanding and action steps when correction is required. |
12/15/2024
| Implemented |
| 6400.113(a) | Individual 1 received fire safety training on 4/11/2024. There was no annual fire training from 2023 on file which would be the initial fire safety training due to date of admission. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Fire Safety training will be conducted by the fire safety coordinator with all individuals initially and annually by the required time. |
12/01/2024
| Implemented |
| 6400.141(c)(10) | For individual 1's initial physical -- 11/18/2022 missing statement related to 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. | Program Specialist will review all new individuals physical prior to transitioning. If the physical form does not contain the required information per regulations upon transition the individual will be taken to urgent care and or PCP to get a physical using the appropriate physical form that reflects the required information. |
12/01/2024
| Implemented |
| 6400.142(a) | For individual 1, a physical appears to be completed 2/6/2024, but it was signed 11/7/2024. The previous physical on file was completed 11/18/2022 which exceeds the annual physical requirement. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | House Manager will schedule annual physical prior to due date annually. House manager will get physical form completed during doctor visit. |
12/01/2024
| Implemented |
| 6400.151(a) | Staff 2 did not have a physical exam in the record at the review. | 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. | Human Resources Manager will provide all prospective employees with preemployment physical form to be completed and submitted prior to direct contact with an individual |
12/01/2024
| Implemented |
| 6400.151(c)(3) | Staff 1's annual physical dated 5/22/23 did not have the following sections completed by the physician:
A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but can work in the home if specific precautions was not indicated on the physical exam. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Human Resource Manager will provide all prospective employees with the company compliant physical form to be completed and submitted for review prior to direct contact with an individual |
12/01/2024
| Implemented |
| 6400.151(c)(4) | Staff 1's annual physical dated 5/22/23 did not have the following sections completed by the physician,
The information if the staff had medical problems which might interfere with the health of the individuals was not indicated on the physical exam. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Human Resource Manager will provide all prospective employees with the company compliant physical form to be completed and submitted for review prior to direct contact with an individual |
12/01/2024
| Implemented |
| 6400.171 | Opened bottles of mustard, ketchup, BBQ sauce, dipping sauce, and pasta sauce were found in kitchen cabinets. These food items require refrigeration after opening. | Food shall be protected from contamination while being stored, prepared, transported and served.
| House manager will conduct a weekly kitchen inspection to assure all food is refrigerated as required |
12/01/2024
| Implemented |
| 6400.181(a) | For individual 1, an assessment from 2/27/2023 was found on file. The most recent assessment found on file is dated 4/10/2024. The 2024 document states last assessment completed 6/10/2023 however it was not found. | 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. | Program Specialist will complete an assessment for all new indiviuals 60 days from transition date and annually thereafter. |
12/01/2024
| Implemented |
| 6400.216(a) | The individuals' books are being kept unlocked in a glass doored sideboard in the dining room. | An individual's records shall be kept locked when unattended.
| All individuals books will be kept locked when not in use |
12/01/2024
| Implemented |
| 6400.217 | For individual 1, there was no release of information found on file. A catch-all form stated that the release of information may have been shared on 4/10/2024. There was no documentation of release of information upon initial admission. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Program Specialist will review and have individuals complete intake and annual documents, signing, copying, and place in file |
12/01/0124
| Implemented |
| 6400.34(a) | For individual 1, no initial individual rights or release of information found on file. A catch all form states individual rights may have been shared on 4/10/2024. There is no documentation of rights shared upon initial admission. | 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. | Program Specialist will review and have individuals complete intake and annual documents, signing, copying, and place in file |
12/01/2024
| Implemented |
| 6400.46(b) | Staff 1 received the annual fire safety training on 7/7/2023, the next training was due by 7/2024. The record did not include an annual training for 2024. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Fire sSafety trainer will complete initial and annual training for all employees |
12/01/2024
| Implemented |
| 6400.52(c)(1) | The record review revealed that staff 1 and staff 2 did not complete the training during the 2023 training period. | 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. | Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training |
12/01/2024
| Implemented |
| 6400.52(c)(2) | The record review revealed that staff 1 and staff 2 did not complete the training for the 2023 training year. | 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. | Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training |
12/01/2024
| Implemented |
| 6400.52(c)(3) | The record review revealed that staff 1 and staff 2 did not complete the training for the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training |
12/01/2024
| Implemented |
| 6400.52(c)(4) | The record review revealed that staff 1 and staff 2 did not complete the training for the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training |
12/01/2024
| Implemented |
| 6400.52(c)(5) | The record review revealed that staff 1 and staff 2 did not complete the training for the 2023 training year. | 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. | Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training |
12/01/2024
| Implemented |
| 6400.52(c)(6) | The record review revealed that staff 1 and staff 2 did not complete the training for the 2023 training year. | 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. | Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training |
12/01/2024
| Implemented |
| 6400.165(b) | Individual 1's MAR does not accurately reflect the script labels on the following medications:
- Balmex (MAR- "Apply to buttocks as directed." Script label- "apply topically three times per day as needed (rectal pain or itching).")
- Omeprazole (MAR- "take one capsule by mouth at bedtime." Script label- "take one capsule by mouth nightly.")
- Ibuprofen (MAR- "take two tablets by mouth every six hours as needed for pain." Script label- "take two tablets (400mg total) by mouth every six hours as needed for pain. Take with food. Do not take every day.") | A prescription order shall be kept current. | House manager will note the exact and explicit directions from the prescription on the MAR |
12/01/2024
| Implemented |
| 6400.165(g) | For individual 1, psychotropic medication reviews weren't found in the file. | 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. | House Manager will schedule psychotropic medication review within 90 day timeframe and complete/obtain required documentation fro all in person and virtual appointments |
12/01/2024
| Implemented |
| 6400.166(a)(2) | For Individual 1, the prescription details on the MAR do not include the prescriber's name. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | House manager will note the prescribers name on the MAR/MedicalRecord |
12/01/2024
| Implemented |
| 6400.194(a) | Individual 1 has a Behavior Support Plan on file dated 6/4/2024 that indicates restrictive procedures. It is not signed by the behavioral specialist or anyone else apart from the agency's team. There is no documentation showing that a Human Rights Team exists or a record of Human Rights Team meetings being held. | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | BSP will be signed by Behavior Specialist and house staff. Documentation of Human Rights Committee Review of Restrictive Procedures minimally biannually |
12/01/2024
| Implemented |
| 6400.213(1)(i) | For individual 1, the face sheet was missing documentation of communication and language, and identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Program Specialist will amend face sheet to include all the required information per the regulations |
12/01/2024
| Implemented |