| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The oven door handle fell off when in use and is in need of repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | In accordance with 55 PA Code 6400.67(a), the Program Specialist had the oven door handle repaired by the handyman on 2/10/2025. |
02/10/2025
| Implemented |
| 6400.113(a) | Individual #1 did not receive a fire safety training. | 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. | In accordance with 55 PA Code Chapter 6400.113(a), the Program Specialist has made several attempts to have Individual #1 fire safety trained.. Because of individual #1 refusal and 48- day psychiatric hospitalization, the Program Specialist will reschedule the fire safety training and have it completed by 4/18/2025 |
04/18/2025
| Implemented |
| 6400.141(a) | Individual#1 did not have a physical exam on file at the time of the review. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | In accordance with 55 PA Code Chapter 6400.141(a), the Program Specialist has made several appointments to have Individual #1 have the appropriate Physical exam and TB screening. Because of individual #1 refusal and 48- day psychiatric hospitalization, the Program Specialist will reschedule the physical exam and have the completed form by 4/30/2025 |
04/30/2025
| Implemented |
| 6400.32(r) | Individual #1 - The provider's individual rights form did not indicate if the individual was informed of the choice to not have a lock on their bedroom door in accordance with the "Informing and Encouraging Exercise of Rights." | An individual has the right to lock the individual's bedroom door. | In accordance with 55 PA Code Chapter 6400.32(r), the CFO has updated the individual rights form indicate that the individual was informed of the choice to not have a lock on their bedroom door. The new form with the updated right has been added to the agency¿s residential admission packet effective 3/1/2025. |
03/01/2025
| Implemented |
| 6400.162(a) | The staff for individual #1 administrated medication with without receiving the ODP medication administration course. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | In accordance with 55 PA Code Chapter 6400.162(a), the agency's CFO has arranged to contract with Honest Elite Caregivers, a PA home health agency, to provide LPN's to administer medications to all residents. The agency CFO has also contracted with an ODP approved medication administration trainer to train all staff including the CFO and Program Specialist appropriately. Both the CFO and Program Specialist have begun the medication administration training as of 1/29/25, and all staff have been enrolled in the course as of 1/29/25. an LPN, has agreed to administer all 8pm medications on 1/29/25, and the home health agency nurses will begin administering for all medication times on 1/30/25. The CFO, and Program Specialist will be appropriately trained and certified to administer medication by 2/15/25. Moreover, the Program Specialist will ensure that at least ¼ (OR 5) of DSP¿s employed by the agency are also medication administration trained and certified by 3/1/12025. |
03/01/2025
| Implemented |
| 6400.162(b)(1) | The staff for individual #1 administrated medication with without receiving the ODP medication administration course. | A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications. | In accordance with 55 PA Code Chapter 6400.162(a), the agency's CFO has arranged to contract with Honest Elite Caregivers, a PA home health agency, to provide LPN's to administer medications to all residents. The agency CFO has also contracted with an ODP approved medication administration trainer to train all staff including the CFO and Program Specialist appropriately. Both the CFO and Program Specialist have begun the medication administration training as of 1/29/25, and all staff have been enrolled in the course as of 1/29/25. an LPN, has agreed to administer all 8pm medications on 1/29/25, and the home health agency nurses will begin administering for all medication times on 1/30/25. The CFO, and Program Specialist will be appropriately trained and certified to administer medication by 2/15/25. Moreover, the Program Specialist will ensure that at least ¼ (OR 5) of DSP¿s employed by the agency are also medication administration trained and certified by 3/1/12025. |
03/01/2025
| Implemented |
| 6400.163(d) | Individual #1's medications were not kept in a locked box. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | In accordance with 55 PA Code Chapter 6400.163(d), the Program Specialist has added a cabinet to the site that can be locked in order to ensure compliance with the regulation effective 1/30/2025 |
01/30/2025
| Implemented |
| 6400.169(a) | The staff for individual #1 administrated medication with without receiving the ODP medication administration course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | In accordance with 55 PA Code Chapter 6400.162(a), the agency's CFO has arranged to contract with Honest Elite Caregivers, a PA home health agency, to provide LPN's to administer medications to all residents. The agency CFO has also contracted with an ODP approved medication administration trainer to train all staff including the CFO and Program Specialist appropriately. Both the CFO and Program Specialist have begun the medication administration training as of 1/29/25, and all staff have been enrolled in the course as of 1/29/25. an LPN, has agreed to administer all 8pm medications on 1/29/25, and the home health agency nurses will begin administering for all medication times on 1/30/25. The CFO, and Program Specialist will be appropriately trained and certified to administer medication by 2/15/25. Moreover, the Program Specialist will ensure that at least ¼ (OR 5) of DSP¿s employed by the agency are also medication administration trained and certified by 3/1/12025. |
03/01/2025
| Implemented |