| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The overhead light in the garage was not operable. Staff replaced the lightbulb and thereby making the light operable at the time of inspection. The outside light located at the rear of the home over the sliding door was not operable at the time of inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Backyard light, located at 919 Emerson Street, Philadelphia, PA 19111, has been replaced and tested, and is now operable as of 4/7/2025. |
04/07/2025
| Implemented |
| 6400.68(b) | The water temperature in the home exceeded 120°F. Measuring in the individual's bathroom, 135°F, the hall bathroom 129°F and the basement bathroom 128°F. The agency corrected the water temperature by turning down the water temperature at the water heater in the home and provided video proof of the temperature measuring below 120°F in all three bathrooms of the home within 24 hours of the inspection. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Provider recalibrated water heaters. Proof of correction submitted on 4/2/2025. Email has been sent to licensing representative. |
04/02/2025
| Implemented |
| 6400.104 | The letter to the fire department does not include the exact location of the bedroom for the individual who resides in the home that needs assistance evacuating in the event of a fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The exact location of the individual¿s bedroom has been added to the fire
department letter and resent. The letter has been updated as of 4/7/25 and revised on 4/28/2025. |
04/07/2025
| Implemented |
| 6400.113(a) | There was no fire safety training conducted for Individual #1 upon the admission date of 3/23/25. | 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. | Fire safety training for Individual #1 has been completed on 4/11/2025 with the individual and program specialist. A certificate has been attached. |
04/11/2025
| Implemented |
| 6400.217 | There was no written consent in Individual #1's record at the time of the review. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Written consent form has been completed for Individual #1 by his brother on 4/10/2025 and was also reviewed with the individual on 4/10/2025. |
04/10/2025
| Implemented |
| 6400.166(a)(11) | The medication administration record (MAR) for individual #1 does not include diagnosis or purpose for the medication, including pro re nata, for any of the individual's prescribed medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Optimal will be switching to Community Care RX pharmacy, 7601 Castor Avenue,
Philadelphia, PA. New MAR will reflect the prescribing physician, medication,
dosage, time, route, and reason. Letters were sent to each physician based on
the individual's prescriptions, reason for medication, and to confirm all medication
details. Moving forward, Community Care RX will be creating the MAR and
updating the MAR when changes occur. |
05/01/2025
| Implemented |