| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | Individual #3, Financial is being cited for several issues. Up to and including there was no separate record of financial resources, the individuals file included receipts of staff, the dates and amounts of deposits and withdrawals did not match, funds that were given to the individual were not recorded clearly and documentation by actual receipt and /or expense record did not match, purchases that exceeded $15 could not be found on the ledger the agency provided. Bank statements did not match up with receipts and there was evidence of commingling of the individuals' personal funds. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | The individual's receipts now include a number system to simplify tracking. The ledgers will show the individuals name, date of purchase, and a number. Bank withdrawals are not always made on the same date as when making some purchases. For example, booking a trip. Booking a trip requires a major credit card. The credit card statement and the bank withdrawal statement will be attached to each other and numbered to reflect the dates of charges. |
08/09/2023
| Implemented |
| 6400.65 | The bathroom located in the basement of the home did not have a window or mechanical ventilation system.. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| A mechanical ventilation system was installed. The house manager is responsible for checking and using the weekly checklist to make sure all furniture and appliances or operational and functional. The issues and concerns will be reported to the program manager immediately, and the fixed within 3 days but no later than 7 depending on the severity. |
08/10/2023
| Implemented |
| 6400.76(a) | The dishwasher in the kitchen was not operational and contained standing water with a foul odor when opened. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Staff will run the dishwasher cleaner at least once a week. Corrected on site. |
08/07/2023
| Implemented |
| 6400.82(e) | The shower located in the basement did not contain a non-slip surface or a slip mat. | Bathtubs and showers shall have a nonslip surface or mat. | A shower mat was placed in the basement shower. corrected on site. |
08/07/2023
| Implemented |
| 6400.141(c)(10) | Individual #3 physical exam dated 07/05/23 did not indicate if he was free from communicable disease. | 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 nurse will follow up with all physical examination forms to be sure all parts are completed. The nurse will use the physical examination check list.
The nurse will be responsible for checking all medical forms. The program director will be responsible for going over the checks with the nurse. |
08/10/2023
| Implemented |
| 6400.142(a) | Individual #3 did not have a dental examination performed annually. Individual was not seen in 2022. Individual had a follow-up appointment scheduled for 05/07/2020, he did not attend this appointment. He was then taken to the dentist on 08/06/2021 and could not be seen based on insurance issue and no other appointment was made. Individual was not seen again at the dentist until 07/31/2023. | 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. | The nurse was retrained on the specific regulations. A dental and medical checklist will be used by the nurse to check that all appointments are completed on a timely basis and that all questions and information is filled out.
The nurse will be responsible for checking compliance once a week. The program Director will be responsible for checking compliance once a month. |
08/10/2023
| Implemented |
| 6400.151(c)(2) | Staff #2 did not have a Tuberculin skin test completed on physical exam dated 02/07/2022, last TB screening was completed 02/26/2020. | 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. | The nurse was retrained on the specific physical examination regulations. A medical checklist will be used by the nurse to check that all appointments are completed on a timely basis and that all questions and information is filled out.
The nurse will be responsible for checking compliance once a week. The program Director will be responsible for checking compliance once a month. |
08/10/2023
| Implemented |
| 6400.46(b) | The Program specialists, Staff #1 and direct service workers are not being trained annually by a fire safety expert, the credential was not provided during the inspection. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Provider will ask that all credentials are given at the time of trainings. |
08/10/2023
| Implemented |
| 6400.52(b)(1) | CEO Training did not contain subjects related to his job. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | The CEO will schedule ahead the following complete 12 hours of training each year:
(1) Management, program, administrative and fiscal staff persons. according to PA Code 6400.52 |
08/10/2023
| Implemented |
| 6400.165(b) | Medication TYLENOL 325mg TAB is listed on the August 2023 MAR, the medication was not in the individual's med box at time of inspection. | A prescription order shall be kept current. | The staff were all retrained on checking and following the steps and rights for medication administration. The nurse was retrained on the specific regulations. The nurse will check and verify all medications are listed on the MAR and medications that are not signed, discontinued or has expired destroyed in a safe manner according to Federal and State statutes and regulations.
The nurse will be responsible for checking compliance once a week. The program specialist and program director will be responsible for checking compliance once every two weeks. |
08/10/2023
| Implemented |