| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #1 -- Criminal background Check occurred on 3/11/25 and DOH was 2/18/25
Staff #2 -- Criminal background Check occurred on 3/16/25 and DOH was 2/24/25 | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| 4/23/2025 ¿ Hiring process and procedures policy was updated to include the following specific language: ¿New team member¿s background checks must be completed within 5 working days after the team member¿s official date of hire noted¿. Agency provided training to Human Resource Manager on the updated standards and expectations in regards to the hiring process and completing background checks. |
04/23/2025
| Implemented |
| 6400.43(b)(1) | Administration needs to develop a clear Policy for reviewing staff criminal background checks on an individual basis in instances when a staff comes back with a criminal history on their record. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | 04/21/2025 ¿ Provider created policy for human resource department that governs the administrative approval of the Chief Executive Officer for any prospective team members with criminal background records. The process includes initial response from ePATCH (PA State Police Record Checks) that includes cascading the record for review to the CEO in the event that the prospective employee has a standing record. The Chief Executive Officer must review the profile in full, including completion of the Background Administrative Review Form, created by the agency on 4/21/2025. The implementation of this new policy will allow for reviews to be appropriately conducted to ensure that the prospective team member meets the standards that will satisfy the proper delivery of services. |
04/21/2025
| Implemented |
| 6400.113(a) | Individual #1 did not have a fire safety training completed upon admission to the program, it was completed at a later date. | 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. | 04/21/2025 ¿ A new policy was created in regards to governing intake checklist and items of completion that must be put in place prior to following through with first day transition. Included within the policy is the new requirement for all new individuals entering the residence to receive fire safety training within their immediate residence on the first day they enter the home. This is to ensure health and safety of the individual, and that the individual understands their routes of exit and how to act quickly and safety within their new residence. |
04/21/2025
| Implemented |
| 6400.151(c)(2) | The physical exam for staff #2 did not include date of tb test. | 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. | 04/24/2025 ¿ New Annual Physical Form directly governed by the agency was created in order to ensure that all standards of the regulation are met in regards to expectations for physical completion. The new physical form is supplemented by a policy created on 04/24/2025, supporting the expectations for completing the form accurately. These expectations include a statement of being free from communicable diseases, PPD & Chest X-Ray result field, as well as a field that allows for the physician to ensure that the team member does not have any medical complexities that will prevent from the team member to being able to complete their duties in the fullest. Previous physical form utilized was the individual physical form provided by PCHC which did not encompass all the required information sought for inspection. Team member returned completed physical to agency, however team member no longer employed under our agency. |
04/24/2025
| Implemented |
| 6400.151(c)(3) | The Physical Exam for Staff #2 did not indicate if person is free from communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | 04/24/2025 ¿ New Annual Physical Form directly governed by the agency was created in order to ensure that all standards of the regulation are met in regards to expectations for physical completion. The new physical form is supplemented by a policy created on 04/24/2025, supporting the expectations for completing the form accurately. These expectations include a statement of being free from communicable diseases, PPD & Chest X-Ray result field, as well as a field that allows for the physician to ensure that the team member does not have any medical complexities that will prevent from the team member to being able to complete their duties in the fullest. Finally, a notation regarding the role and responsibility of the human resource team and residential team was effectively mapped out to ensure clear defined duties and responsibilities in the process are clear. |
04/24/2025
| Implemented |
| 6400.166(a)(4) | PRN for moisturizer for individual #1 with prescription label was in their medication box, however it was not listed on the medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | 4/22/2025 ¿ Provider¿s policy of ¿Medication Documentation and Administration¿ was updated to include a policy that governs the medication within the medication box. The statement reads as the following ¿All medications present in the medication storage container must have accompanying documentation of administration noted on the Medication Administration Record for the respective month¿. The medication intake process was also updated to include a dual-review step process that includes initial intake performed by the Lead Direct Support Professional (LDSP), and dually verified by the agency registered nurse. |
04/22/2025
| Implemented |