| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff Person #1 was hired 9/23/2024. Background check completed 3/10/2025. | 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.
| This error was self corrected during a self audit. Staff number 1 was hired but QA failed to print the criminal report (initially) as a corrective to the error a new criminal history check was completed on 3/10/2025 |
04/21/2025
| Implemented |
| 6400.67(a) | The lint trap in the dryer was broken, making it difficult to remove and clean. A new lint trap was purchased and it was replaced the day of inspection. | Floors, walls, ceilings and other surfaces shall be in good repair. | A new lint trap was purchased and installed during inspection |
04/07/2025
| Implemented |
| 6400.107 | Portable space heater was found in the basement. The unit was removed during the inspection. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The portable heater was removed during inspection |
04/07/2025
| Implemented |
| 6400.111(a) | Fire extinguishers are 1A rated, regulatory minimum is 2A. These have already been purchased and updated in the homes. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 2a rating fire extinguishers were replaced and installed during inspection |
04/07/2025
| Implemented |
| 6400.111(c) | Fire extinguishers are 1A rated, regulatory minimum is 2A. These have already been purchased and updated in the homes. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | 2a ratings fire extinguishers were replaced and installed during inspection |
04/07/2025
| Implemented |
| 6400.141(a) | No physical found on file for Individual #1. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual number 1 has a scheduled physical appointment on 04/21/2025 |
04/21/2025
| Implemented |
| 6400.144 | For Individual #1, Metoprolol Succinate 5mg tablets and Diphenhydramine 25mg PRN tablets were not present during the inspection. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The med trainer called the pharmacy to see what was the issue with the outstanding medications that were missing, this was a pharmacy issue as these medications were newly prescribed and not yet administered to individual number 1 . Once the medication has been delivered to the house staff will document and administer |
04/28/2025
| Implemented |
| 6400.24 | The 1970 Controlled Substances Act requires accurate counts be kept for controlled medications. For Individual #1, Diazepam 2mg tablet control count states 14 on hand, however 47 were counted by the inspector. Diazepam 5mg tablet control count states 24 on hand as of yesterday morning, however 22 were counted by inspector. Accounting for the meds that were distributed yesterday and this morning, the count is correct at 22. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The controlled count sheet was corrected on 4/7/25 after the inspection by the med trainer . There were an large amount of CS medication , the med trainer added the overage to the lock box but fail to update the list . |
04/07/2025
| Implemented |
| 6400.163(a) | Majority of Individual #1's prescription medications did not have a pharmacy-issued label. The medicines were labelled with individual contents of the packages and were the correct dosages to fit orders for the individual | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Individual number 1 medications were given to the agency by Norristown State Hospital Pharmacy during discharge. They gave sample medications for his meds because during his admission he did not have insurance to get medication from another pharmacy. This issue is still on going to see how the situation can be fixed |
05/12/2025
| Implemented |