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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 was admitted to the home on 10/27/23 and completed fire safety training upon admission. The next documented fire safety training for the individual was 7/13/25 and 7/19/25. Fire safety training was not completed annually as required by regulation, as more than a year elapsed between when the two trainings occurred. | 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. | As a standard, in alignment with 55 PA Code Chapter 6400.113(a), the agency routinely provides instructions in the consumer's primary language or mode of communication, on admission and annually thereafter. The instructions cover topics on general fire safety, evacuation procedures, and responsibilities, including fire drills. Consumers are also instructed about the designated meeting place outside the building or in a fire-safe area in the event of an actual fire, along with smoking safety procedures, when applicable.
During a licensing inspection on 8/05/2025, the inspector identified that a consumer admitted to a home on 10/27/23 completed fire safety training upon admission, and again on 7/13/25 and 7/19/25. One of the July 2025 documentation items is a typographic error. The agency has taken corrective actions to address this issue and will implement processes to proactively identify and correct any typos in documentation, demonstrating our commitment to compliance. |
09/02/2025
| Implemented |
| 6400.141(c)(14) | The 10/8/24 annual physical completed for individual #1 does not include information pertinent to diagnosis and treatment in case of an emergency. The line on the 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. | During a licensing inspection on 8/05/2025, it was identified that a 10/8/24 annual physical record completed by a consumer's primary care provider left the line designated for information pertinent to diagnosis and treatment in case of an emergency blank. However, there is documentation in the individual's Health record that lists all diagnoses and treatments in case of an emergency. The failure of a primary care provider to include pertinent information in annual health physical records for emergency diagnosis and treatment constitutes a violation that requires resolution and ongoing compliance assurance. The agency has taken corrective actions to address this issue. All completed annual physical records for agency consumers will be reviewed by the Director of Quality Management (DQM) biannually to ensure that primary care clinicians complete each consumer's annual health records form in its entirety. |
09/02/2025
| Implemented |
| 6400.144 | Individual #1 physician recommended that mammograms should be completed annually on a 12/4/23 medical visit form. There was no documentary evidence that annual mammograms have occurred since the doctor's recommendation was made. | 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.
| As a standard, the agency religiously arranged for consumers to follow through on medical, nursing, pharmaceutical, dental, dietary, and psychological services prescribed for the individual served. Post the conference call of the 8/05/2025 licensing inspection, an inspector reported that an Individual's physician had recommended annual mammograms. However, the latest recommendation from the individual physician was for a mammogram every 2 years (biennially), NOT annually. The individual's health record includes a copy of the last mammogram, performed on 12/5/23; the next mammogram is due on 12/4/25. The inspector overlooked the 12/5/23 mammogram result in the consumer's health record, and no inquiry about the mammogram result was made to agency leaders during the inspection. It was rather documented as a violation. The violation must be addressed. So the agency took corrective action to address this issue. Moving forward, the records of consumers' prescribed treatments or tests, such as medical, nursing, pharmaceutical, dental, dietary, and psychological services, shall be logged, reviewed biannually by the Director of Quality Management (DQM), and reported to the licensing inspectors during their annual licensing visits, minimizing the tendency of human error to overlook and ensuring ongoing compliance. |
09/02/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medication. Documentation in the record showed psychiatric appointments for medication review occurred only on 8/12/24, 6/13/25 and 7/24/25. According to the documentation in the record, review by a licensed physician, at least every 3 months, that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage did not occur. | 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. | As a standard, the agency requires consumers to attend quarterly psychiatric appointments for medication reviews and also requires clinicians to document the reasons for prescriptions, ongoing use, and dosage changes. Following the 8/05/2025 licensing inspection, an inspector reported that an individual prescribed psychotropic medication has psychiatric appointments for medication review by a licensed physician that occurred on 8/12/24, 6/13/25, and 7/24/25, which violates the 55 PA Code Chapter 6400.165(g) regulation requiring quarterly med reviews for consumers on psychotropic medications. However, the referenced individual was not on psychotropic medications before 6/13/25, so the agency complied with 55 PA Code Chapter 6400.165(g). Now that the inspector has made a violation report, it must be addressed. The agency has taken corrective actions to address this overlook issue. The agency will use a log to record when psychotropic medications are started, which will be reviewed biannually by the Director of Quality Management (DQM) and reported to the licensing inspectors during their annual licensing visits, ensuring compliance. |
09/02/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | The home had 3 levels, main floor, second floor and basement, and the smoke detectors were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Agnew House Record of Plan of Correction-7/10/2020 LIS
1. The Plan to fix the immediate problem
The VP Operations requested a contractor to replace the broken smoke detectors with functionally interconnected smoke detectors. New interconnected smoke detectors are needed, one to be placed on each level of the home.
After learning that Agnew House smoke detectors are inoperable, the VP of Operations hired a qualified contractor to replace the inoperative smoke detectors. The three interconnected smoke detectors, one on each level of the home was replaced the same day, 7/10/2020 when it was found to be inoperable
2. A plan to prevent future occurrences
Every month, staff will check and document the operability of the home¿s interconnected smoke detectors as part of monthly fire drills. Two HHHS policies (1) Fire Drills and 2) Smoke dectectors_Fire Alarms_Inoperable policy, along with HHHS fire drill forms, will serve as the framework to prevent future occurrences. These policies outline a process of monthly assessment of the operability of the smoke detectors. The fire Drill forms serve as a record of compliance |
07/10/2020
| Implemented |
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