| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The provided financial information was not readable (files could not be opened), making an accurate review of the individual's financial management impossible. | 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. | Individual¿s #1 family member is the rep payee for all finances. Individual #1 monthly EBT finances and cash on hand funds are squarely balanced every month to ensure accuracy. Financial documents were attached with all supporting documents. |
01/10/2023
| Implemented |
| 6400.62(d) | There was a case of water housed in the closet with chemicals, this was removed during inspection. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | The case of water was immediately removed during licensing inspection without delays. |
11/30/2022
| Implemented |
| 6400.64(a) | Dome light in kitchen filled with debris, needs to be cleaned.
Vent in the hallway was filled with dust, needs to be cleaned. | Clean and sanitary conditions shall be maintained in the home. | All the vents in the home were properly cleaned immediately after licensing inspections that day. |
11/30/2022
| Implemented |
| 6400.68(b) | The hot water temp in the bathroom was 125.4 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The electric water thermostat was adjusted to the desired water temperature right after licensing inspection. The home current temperature is below 120. |
11/30/2022
| Implemented |
| 6400.72(a) | There were multiple windows in the home that were not screened.
No screen in living room window on the right.
Large window in Vacant bedroom#1 was not screened.
Both windows in individual#1's bedroom were not screened.
Unscreened window in vacant bedroom#2. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The missing window screens were immediately installed right after licensing inspection. |
11/30/2022
| Implemented |
| 6400.181(e)(6) | The current assessment does not indicate individual#1's awareness of poison safety. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The Individual¿s Annual Assessment has been updated and the updated copy includes information about the individual¿s awareness of poison safety. |
11/30/2022
| Implemented |
| 6400.181(e)(7) | The current assessment does not indicate individual#1's ability to recognize the danger of heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The Individual¿s Annual Assessment has been updated and the updated copy includes information about the individual¿s ability to recognize the danger of heat sources. |
11/30/2022
| Implemented |
| 6400.181(e)(14) | The current assessment does not indicate the individual's ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The Individual¿s Annual Assessment has been updated and the updated copy includes information about the individual¿s ability to swim. |
11/30/2022
| Implemented |
| 6400.24 | Staff member#1 did not have a completed FBI background check prior to date of hire. Pennsylvania residency for two years prior to 6/12/22 hire date was not verified.
Staff member#2 did not have an FBI background check prior to 4/1/2022 date of hire. FBI Background checks were not verified for newly hired staff. Verification of Pennsylvania Residency for two years prior to dates of hire was not provided. Documentation from the agency that newly hired staff resided in Pennsylvania two years prior to hire or a completed FBI check was not provided. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Staff member #1 did not have a need to complete an FBI background check because of continuously residency in the State of Pennsylvania over the past two years and more without relocation. |
01/10/2023
| Implemented |
| 6400.50(a) | A training record or syllabus was not provided for staff members#2, #3 for the most recently completed stated training year from July 1, 2021, through June 30th, 2022. Non-emergency trainings completed were not documented during review.
An accurate account of staff training was not documented clearly for Restrictive dietary guidelines for individual#1. The staff training sign-in sheet contained signatures, but printed names were not notated. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The company has been using an orientation and annual staff training log, which staff has been entering their trainings. A training syllabus has been created as well to ensure that all agency employees entered all their trainings with the date of completion. |
11/30/2022
| Implemented |
| 6400.51(a)(1) | Staff member#1 did not receive orientation training prior to working with individuals and within 30 days of hire on 6/12/2022. The required trainings for orientation were not documentation as completed until 10/14/22.
Orientation Training for staff member#2was not completed within 30 days from the date of hire on 4/1/2022 and prior to working with individuals. The majority of required training was documented as completed on 10/20/2022 | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Agency Policy and procedure has been updated on trainings to ensure that all employees complete all their trainings before they start work as per PA 6400 regulations requirement during first week of orientation. |
11/30/2022
| Implemented |
| 6400.165(c) | Medication blister packs were not used, pill box indication day of the week was full. It appeared that the meds were not administered but were signed out on the mar for all medications. | A prescription medication shall be administered as prescribed. | The Individual¿s medications were all administered as prescribed, but the staff members were administering the pill bottle medications instead of the blister pad medications. All his medications are now in a blister pad. All pill bottles have been returned to the Pharmacy. |
11/30/2022
| Implemented |
| 6400.166(a)(13) | The medication records did not include the name and initials of person administering medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The MARs were immediately sign and initialed by the program staff right after the licensing inspection. Agency Director of Operations completed a review of PA 15 Medication administration steps to ensure that medications are administered as prescribed. |
11/30/2022
| Implemented |
| 6400.167(a)(1) | Medication blister packs were not used, pill box indication day of the week was full. It could not be determined if the medications were administered although they were signed out on the mar for all medications. This is considered a Medication error. | Medication errors include the following: Failure to administer a medication. | The Individual¿s medications were all administered as prescribed, but the staff members were administering his bottle medications instead of the blister pad medications. All his medications are now in a blister pad. All his bottle medications has now been returned to the Pharmacy. |
11/30/2022
| Implemented |
| 6400.213(1)(i) | On the face sheet, individual#1's height and identifying marks sections are blank.
The current physical, as well as his medical history, does not report individual#1's height. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | This information on the Individual¿s Lifetime Medical history has been updated has been updated and the individual¿s height section has been completed. A new copy has been printed and added in his permanent/medical record books. |
11/30/2022
| Implemented |