| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The following new hire staff members had state background checks which occurred greater than five days after their date of hire.
Staff #2 - Hired 12/4/21, Criminal History Check 2/15/22
Staff #5 - Hired 12/4/21, Criminal History Check 3/5/22
Staff #1 - Hired 12/4/21, Criminal History Check 2/15/22 | 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.
| Health1st routinely completes criminal background checks before staff can work with individuals. During licensing inspection on 8/12/2022, three Staff members' records indicated that their criminal background checks occurred after five days of hire. The initial criminal background check records that were completed for these three individuals were misfiled. Thus, another criminal background check occurred after five days window. Post inspection, the Director of Quality Management (DQM) implemented a new hire checklist that includes a check to ensure the new staff's criminal background checks are completed within five days and appropriately filed before being assigned to support an individual. Education and training about compliance with 55 PA Code Chapter 6400.21(a), underscoring the imperative for new hires to have a criminal background check on file before hire, was completed on 8/16/22. |
08/16/2022
| Implemented |
| 6400.68(b) | The water temperature 128.3 degrees | Hot water temperatures in bathtubs and showers may not exceed 120°F. | During licensing inspection on 8/12/2022, it was noted that the home water temperature exceeded the recommended maximum of 120.0 degrees Fahrenheit. The home water temperature nob was adjusted until the water reached and maintained a highest of 117 degrees Fahrenheit. The water temperature was then checked daily for two weeks. It was found to vacillate between 115 degrees Fahrenheit and 117 degrees Fahrenheit, maintaining temperature stability that is lower than 120.0 degrees Fahrenheit which complies with 55 PA Code Chapter 6400.68(b) |
08/26/2022
| Implemented |
| 6400.82(e) | There was no non-slip surface in the upstairs bathroom. | Bathtubs and showers shall have a nonslip surface or mat. | During licensing inspection on 8/12/2022, it was identified that the non-slip surface mat in the upper-level home bathtub was missing. A non-slip shower floor mat was purchased and placed in the upstairs bathroom. Individual #1 residing in the home was educated about the safety need to allow the surface mat to remain in the bathtub and was receptive to the education |
08/16/2022
| Implemented |
| 6400.106 | There were no documentation of furnace inspections or cleanings having occurred for the home. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| During licensing inspection on 8/12/2022, the annual furnace inspection had only been scheduled. The furnace inspection was completed on 8/16/22 by a professional furnace company, and the home passed the inspection. The written documentation of the inspection and cleaning completed on 8/16/22 is kept for the records. |
08/16/2022
| Implemented |
| 6400.112(d) | The fire drills that occurred on 6/6/22, and 7/11/22 did not have the evacuation time listed, therefore there was no documentation confirming that the fire evacuation had occurred in less than 2 1/2 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | During licensing inspection on 8/12/2022, it was identified that the documentation of 6/6/22 and 7/11/22 of the monthly fire drills did not have the evacuation time listed. Staff training about appropriate documentation of fire safety drills was completed with staff on 8/16/2022. A fire drill training by a certified fire safety specialist has also been scheduled to occur on 9/29/22. This additional training and education about fire safety and drills for all staff is intended to enhance staff competencies in conducting and documenting fire safety drills and to comply with 55 PA Code Chapter 6400.112(d) |
08/16/2022
| Implemented |
| 6400.113(a) | Fire safety training for individual #1consists only of a signature. There is no documentation showing that the fire safety training contained the outlined items required in the regulations. | 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. | During licensing inspection on 8/12/2022, it was identified that the documentation did not reflect
Fire safety training for individuals as outlined in 55 PA Code Chapter 6400.113(a). Staff training about appropriate documentation of fire safety drills was completed with staff on 8/16/2022. A fire drill training by a certified fire safety specialist has also been scheduled to occur on 9/29/22. This additional training and education about fire safety and drills for all staff is intended to enhance staff competencies in conducting and documenting fire safety drills, as well as training individuals on fire safety and evacuation and documenting appropriately to comply with 55 PA Code Chapter 6400.113(a) |
08/16/2022
| Implemented |
| 6400.151(a) | There was no documentation that the following staff completed their physicals before their date of hire.
Staff #1 -Undated
Staff #2 - Hired 2/7/2022, Physical dated 4/8/2022
Staff #3 - Hired 12/4/21, Physical dated 3/18/22
Staff #4 - No physical on record | 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. | As a standard, Health1st routinely request potential hires to complete health physical before hiring in alignment with 55 PA Code Chapter 6400.151(a). Three of the four staff members' records identified for missing timely health physicals were misfiled. Thus, the replacement health physical record was dated after the hire date. The practitioner for the 4th staff did not date the record. Post inspection, the Director of Quality Management (DQM) implemented a new hire checklist that includes a process to ensure that the prospective employees completed health physical is appropriately signed by the practitioner and filed with the staff record before generating employment offer letters. Education and training about compliance with 55 PA Code Chapter 6400.151(a) underscoring the imperative that new hires have an appropriately signed physical health record on file before the employment offer was completed on 8/16/22 |
08/16/2022
| Implemented |
| 6400.181(e)(5) | Assessment dated 4/22/22 for individual #1 did not include documentation on his ability to self administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Health First provided an up to date assessment for individual which includes the requested information. |
08/12/2022
| Implemented |
| 6400.181(e)(6) | Assessment dated 4/22/22 for individual #1 did not include documentation of his ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Health First provided an up to date assessment for individual which includes the requested information. |
08/12/2022
| Implemented |
| 6400.181(e)(10) | Assessment dated 4/22/22 for individual #1 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Health First provided an up to date assessment for individual which includes the requested information. |
08/12/2022
| Implemented |
| 6400.181(e)(14) | Assessment dated 4/22/22 for individual #1 did not include documentation on his ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Health First provided an up to date assessment for individual which includes the requested information. |
08/12/2022
| Implemented |
| 6400.24 | Klonopin 0.5mg prescribed to individual #1 was not being counted. Under the 1970 controlled substances act, all controlled substances need to be double locked and counted. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | During licensing inspection on 8/12/2022, it was identified that the physical counting record of Medication Klonopin 0.5 mg was not completed as required by 55 PA Code Chapter 6400.24. The Director of Quality Management (DQM) developed a controlled substance counting sheet on 8/12/2022 during the onsite licensing inspection. The physical counting record of medication started on 8/13/2022 and has continued with every change of shift by the nurses who administer medications |
08/16/2022
| Implemented |
| 6400.46(a) | Fire safety trainings for staff were not conducted by a certified fire safety specialist. | 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. | During licensing inspection on 8/12/2022, it was identified that Health1st conscientious effort to secure a certified fire safety specialist from the local firefighter department was futile. Based on insights gained from the licensing inspection on 8/12/2022, Health1st has successfully scheduled a fire safety training to be completed by a certified fire safety specialist organization on 9/29/22 |
09/29/2022
| Implemented |