| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not available for review. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Moving forward 3 to 6 months prior to inspection the self-assessment of each home will be completed. |
12/04/2018
| Implemented |
| 6400.22(d)(1) | Individual #2's ledger mention expenditure was in the amount of $82.00, but a October amount on receipt was $82.20. | 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. | Moving forward all expenditure will be reported monthly by the office manager. K & K HealthCare Service has a policy and procedure in place |
12/04/2018
| Implemented |
| 6400.46(a) | Staff person #1 has no proof of completing orientation before working with individuals. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | The plan in place for K & K HealthCare Service is to complete orientation for each staff person before they began working with the individual. In this case the orientation was completed 11/16/18 but was not place in her record. Moving forward each person orientation with be signed in place in their record. |
11/16/2018
| Implemented |
| 6400.46(d) | Staff person #1 had no trainings in the file for review. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | All trainings for staff person # 1 was reviewed by the inspector and they were all in the file. The inspector made a comment and said that staff person #1completed over the hours of training. My guess this is a misunderstanding. Please find enclose information.
Attachment 5 |
12/03/2018
| Implemented |
| 6400.46(f) | Individual #2 did not have fire safety training ln the file. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | On 01/01/2018, individual #2 completed fire safety training but was not sign. Moving forward when individual's are trained on fire safety it will be sign in put in their record. On 12/04/18, it was signed by individual #2 and placed in the record |
12/04/2018
| Implemented |
| 6400.66 | Individual #1 bedroom did not have operational lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Moving forward the office manager will do monthly inspection of light bulb. This correction was done on 12/04/2018 |
12/04/2018
| Implemented |
| 6400.68(b) | The hot water temperature in the bathroom was 126°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | K & K HealthCare Service hired L & J Heating and A/C and changed the water valve to mixing valve on 01/03/2019. Moving forward water temperature will be monitor daily for the safety of the individual we serve. |
01/03/2019
| Implemented |
| 6400.77(b) | The First Aid Kit is missing Tweezers and scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The plan for the future is to have the manager check the First Aid Kit monthly and replace missing item. On 12/08/19, missing Tweezers and Scissors were replaced. |
12/08/2018
| Implemented |
| 6400.141(c)(3) | Individual #2 has not received a immunization (Tetanus) since 10/31/08). | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The plan moving forward is to check individual's #2 record monthly so as to keep up to date with all of individual's #2 wellbeing. On 01/02/19, individual #2 took tetanus shot. |
01/02/2019
| Implemented |
| 6400.143(a) | Individual #2 does not have a refusal plan. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Moving forward a refusal policy and procedure was developed for the individuals we serve. On 12/13/18, K & K HealthCare Service transported mother to The Court of Common Pleas of Philadelphia County Family Court to pick-up Physical Custody to also make decision for the individual welfare.
Attachment 1 |
12/13/2018
| Implemented |
| 6400.151(a) | Staff person #1 did not have a current physical in the file.
Staff person #2 did not have a current physical in the file. | 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. | Moving forward all staff person working directly with the individuals we serve will complete physical before working with K & K HealthCare Service and yearly after. Staff person completed physical on 12/05/18. Policy and Procedure developed to follow. |
12/05/2018
| Implemented |
| 6400.213(1)(i) | Individual #2's record did not have identifying marks listed. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| Moving forward the plan is to make sure and include individual's identify marks in their assessment, Life Time Medical and Personal information. If the individual does not have identify marks to write (N/A). Correction was completed on 12/08/18 |
12/08/2018
| Implemented |