| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #2's hire date is 12/4/23 and the criminal history check is dated 1/23/24. The background check was not completed within 5 days of hire. The criminal history check is dated for 1/31/24 for staff #3. No record of a criminal HX check being requested within 5 working days after the person's date of hire was found in the record. | 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.
| Manager of Operations will complete Orientation Checklist with staff file to ensure all documents are correct and present (Attachment #2) |
05/14/2024
| Implemented |
| 6400.141(c)(4) | The physical exam for individual #1 did not include: a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Physical completed on 3/7/2024. Vision and hearing screening completed (Attachment #12) |
03/04/2024
| Implemented |
| 6400.141(c)(10) | The physical exam did not note if individual #1 had a communicable disease or not. | 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. | Physical Exam 3/4/2024 with the communicable disease completed (Attachment#12). |
03/04/2024
| Implemented |
| 6400.142(b) | There was no current dental exam on file for individual #1 at the time of the review. | An individual who is using medication known to cause dental problems shall have a dental examination by a licensed dentist at intervals recommended in writing by the dentist. | Appointments were made for Individual but documentation was not kept prior. Implementation of participant refusal form (Attachment#14) was implemented. Earliest dental appointment made for 5/29/24. Team will continue to educate individuals on the importance of doctor appointments. |
05/29/2024
| Implemented |
| 6400.142(h) | There was no current written dental hygiene plan in the records for individual # 1 at the time of the review. | The dental hygiene plan shall be kept in the individual's record. | Appointments were made for Individual but documentation was not kept prior. Implementation of participant refusal form (Attachment#14) was implemented. Earliest dental appointment made for 5/29/24. Team will continue to educate individuals on the importance of doctor appointments. |
05/29/2024
| Implemented |
| 6400.151(c)(2) | The Physical exam is dated for 3/9/23 with no documented TB screening for staff #2 at the time of the review. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Physical was completed on 3/4/24. (Attachment #12). Individual#1 declined TB test after education and testing (Attachment #13). Individual is scheduled for TB on 6/15/24 for second attempt. |
06/15/2024
| Implemented |
| 6400.163(d) | Individual #1 medication was not kept locked. Although this individual self-administers medication; the medications must be kept locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | All medications are kept locked up in a container (Attachment #15) |
04/01/2024
| Implemented |
| 6400.165(g) | The 3-month medication review for individual #1, which was due in January 2024 based on a previous review completed in October was not in the records so it could not be determined if a review was completed. | 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 will attend psych appointments in which appointments will be made upon admission to the home. If a psych appointment is past 90 days or individual is unable to make the appointment, the individual will attend a PCP appointment. All documentation will be maintained in the individual's medical book. |
05/13/2024
| Implemented |
| 6400.194(a) | Knives are kept locked up due to behavioral needs which is considered a restrictive procedure however there was no behavior support plan written and consequently no review by a human rights team. | 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. | Team meeting was held at the monitoring on 3/11/2024. Team discussed sharp objects in which team believed this was unnecessary. This statement was removed from the ISP. |
03/14/2024
| Implemented |
| 6400.195(a) | Knives are kept locked in the home due to Individual #1's known behaviors and there was no Behavior Support Plan in the records. As there was no plan, there was no review and approval from a human rights team. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | Team meeting was held at the monitoring on 3/11/2024. Team discussed sharp objects in which team believed this was unnecessary. This statement was removed from the ISP. |
03/14/2024
| Implemented |