|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.52(c)(2) | Chief Executive Officer #1's annual training for the training year January 1, 2020 to December 31, 2020 did not encompass the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The Chief Executive Officer received training which encompassed the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse on 6/30/21. He also received training regarding the new ODP Incident Management bulletin on 6/25/21. |
08/25/2021
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(f) | Direct Service Worker #1 had training in fire safety on 1/4/17 then again on 1/10/18. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff was retrained on 1/10/18
Staff Development Specialist will send a weekly report to Program Managers that details employees who are approaching their training due date. Program Managers will communicate the requirement to their respective employees. [Immediately and continuing at least quarterly, a designated management staff person shall audit all staff persons' current and past fire safety training and the staff training record to ensure all staff persons are trained timely 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Documentation of audits shall be kept. (AS 5/31/18)] |
05/21/2018
| Implemented |
| 6400.151(a) | Program specialist #2's physical examinations were completed on 11/3/14 then again on 4/6/17. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Program Specialist #2 physical examination was completed on 4/6/17
Software tracking system will be updated to assure timely notice to employees that physicals are due. All physical data will be reviewed in the software to ensure that all data fields are completed . This will be completed by June 15, 2018. The responsible party to ensure the completion of this is Carla Georgal, V.P. of Human Resources. This will prevent recurrence. [Within 30 days of receipt of the plan of correct and continuing at least quarterly for one year, a designated management staff person shall audit a 10% sample of staff persons' current and past physical examinations documentation and the aforementioned tracking system to ensure completion of staff persons' physical examination, timely. Documentation of audits shall be kept. (AS 5/31/18)] |
06/15/2018
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(2) | Individual #1's bed did not have a solid foundation. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Waivers were requested for individual #1. Provider will request Waivers for future similar situations. [In the event that the requested waiver is denied the CEO or designee will ensure Individual #1 is provided a bed with a solid foundation that meets the individual's needs. (AS 4/13/15)] |
03/30/2015
| Implemented |
| 6400.81(k)(4) | Individual #1's bedroom did not have a chest of drawers. | In bedrooms, each individual shall have the following: A chest of drawers. | Waivers were requested for individual #1. Provider will request Waivers for future similar situations. [In the event that the requested waiver is denied the CEO or designee will ensure Individual #1 is provided a chest of drawers that meet the individual's needs. (AS 4/13/15)] |
03/30/2015
| Implemented |
| 6400.171 | A bag of frozen mixed vegetables and a bag of meatballs were unsealed in the refrigerator. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The bag of frozen vegetables and meatballs were discarded. Staff will be retrained in proper food storage. [CEO or designee will ensure food in all homes is protected and all staff are trained in proper food storage. (AS 4/13/15)] |
04/09/2015
| Implemented |
|
|