| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The second dresser knob was missing on individual 1's bedroom dresser. | Floors, walls, ceilings and other surfaces shall be in good repair. | DIVINE SUPPORT SERVICES.
Plan of Correction
Location: 914 South Ave, Apt G2 Secane, Pa 19018 Regulation: 67(a)
What was done immediately to correct the specific issue cited?
A new knob was purchased and installed.
1. What specific change will be made?
A monthly site checklist will be established.
2. Who (by title) will make the change?
Operations Managers will ensure that all repairs are completed and are up to date.
3. When will the change be made?
Immediately.
4. What system has been implemented to make sure the same violation does not occur again?
Monthly site checks will be completed by the operations manager and the findings will be documented on a site checklist.
5. What education and training have been provided to staff?
All staff will be trained on how to complete the monthly site checklist, how to conduct the checks and how to document it.
6. How will we monitor to prevent reoccurrence? Include specific record-keeping, ongoing monitoring activities and action plan follow-up.
Management will ensure that all site checklist is completed on a monthly basis, complete all repairs noted on the site checklist. training during orientation and annually. |
10/02/2020
| Implemented |
| 6400.112(c) | The Fire drill records did not indicate whether or not the fire alarm was tested and if it was operative. Lines were drawn and N.A was written on details line | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Location: 914 South Ave, Apt G2 Secane, Pa 19018 Regulation: 112c
What was done immediately to correct the specific issue cited?
All staff will be retrained on how to accurately complete the fire drill form.
1. What specific change will be made?
Operation Manager will review all fire drills to ensure thoroughness and accuracy
2. Who (by title) will make the change?
Operations Managers will ensure that all monthly fire drills are completed.
3. When will the change be made?
Immediately.
4. What system has been implemented to make sure the same violation does not occur again?
Monthly fire drill forms will be reviewed by the Operation Manager for thoroughness and accuracy every month. Errors will be corrected and if there is need to redo the fire drill will be completed again.
5. What education and training has been provided to staff?
All staff will be trained during orientation and annually thereafter, on how to conduct and complete the fire drill and the form accurately.
6. How will we monitor to prevent reoccurrence? Include specific record-keeping, ongoing monitoring activities and action plan follow-up.
Operation Manager will ensure that all monthly fire drill is completed, and the form completed accurately. |
10/02/2020
| Implemented |
| 6400.144 | Acetaminophen 500mg PRN (to be taken as needed) medication was filled 10/19/18 and noted expiring 9/30/2019 but was still in the medication box to be administered if needed. Bromfed DM syrup was notated as a PRN medication in the record but not found on site at the time of 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.
| DIVINE SUPPORT SERVICES.
Plan of Correction
Location: 914 South Ave, Apt G2 Secane, Pa 19018 Regulation: 144
What was done immediately to correct the specific issue cited?
The medication was sent back to the pharmacy, a new prescription was secured, and a new medication was obtained from the pharmacy.
1. What specific change will be made?
Operation Manager will ensure that all staff will complete a medication and medical record checks at the start of every shift. Incoming and outgoing staff will complete a med check.
2. Who (by title) will make the change?
Operations Managers will ensure that all medication and medical record checks are completed three times a day.
3. When will the change be made?
Immediately.
4. What system has been implemented to make sure the same violation does not occur again?
Daily medication and medical record checks will be reviewed by the Operation Manager for thoroughness and accuracy every day. Errors will be corrected immediately.
5. What education and training have been provided to staff?
All staff will be trained during orientation and annually thereafter, on how to complete and document medication and medical record checks.
6. How will we monitor to prevent reoccurrence? Include specific record-keeping, ongoing monitoring activities and action plan follow-up.
Operation Manager will ensure that all daily medication and medical record checks are completed, and the forms are completed thoroughly accurately. |
10/02/2020
| Implemented |
| 6400.181(c) | The assessment dated 2/1/2020 for individual 1 did not notate how the document it was developed and implemented. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Moving forward, Provider and Program Specialist will work together to ensure that all assessments are based on assessment instruments, interviews, progress notes and observations as recommended by the 6400 regulation |
10/02/2020
| Implemented |
| 6400.46(b) | The Program specialist, staff 1, did not have verification on file that they were trained by a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | DIVINE SUPPORT SERVICES.
Plan of Correction
Location: 914 South Ave, Apt G2 Secane, Pa 19018 Regulation: 46 (b)
What was done immediately to correct the specific issue cited?
A fire safety expert was contacted to complete the training
1. What specific change will be made?
To ensure fire safety training is conducted by a fire safety expert and completed within the specified timeframes for all staffs.
2. Who (by title) will make the change?
Operations Managers and HR will ensure that all staffs are trained by an expert
3. When will the change be made?
Immediately.
4. What system has been implemented to make sure the same violation does not occur again?
Training report will be quarterly to ensure that training is scheduled with an expert in a timely manner. All training with an expert will be added to a training calendar in the office
5. What education and training have been provided to staff?
HR will ensure that training will be conducted by an expert upon hire and annually thereafter to ensure regulatory compliance.
6. How will we monitor to prevent reoccurrence? Include specific record-keeping, ongoing monitoring activities and action plan follow-up.
HR will ensure that all staff complete fire safety training during orientation and annually thereafter. HR will maintain an electronic record system to ensure that all staff complete their training requirement in a timely manner. |
10/02/2020
| Implemented |
| 6400.166(b) | Three medications were not logged on 8/2/2020, dates were left blank. The medications, oxcarbazepine, guanfacine and nuexdexta were not logged. The agency stated individual 1 was with family but no code was provided, the medication log was left blank.
The meaning of H code used on previous month's dates of the individual's medication record was not noted on the back | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | DIVINE SUPPORT SERVICES.
Plan of Correction
Location: 914 South Ave, Apt G2 Secane, Pa 19018 Regulation: 166 (b)
What was done immediately to correct the specific issue cited?
Medication checklist was immediately created to track errors on the medical record
1. What specific change will be made?
Whenever he visits his father staff will indicate on the medical record form HV (home visit).
2. Who (by title) will make the change?
Operations Managers will ensure that all medication and medical record checks are completed three times a day, and all corrections are made immediately.
3. When will the change be made?
Immediately.
4. What system has been implemented to make sure the same violation does not occur again?
Daily medication and medical record checks will be reviewed by the Operation Manager for thoroughness and accuracy every day. Errors will be corrected immediately.
5. What education and training have been provided to staff?
All staff will be trained during orientation and annually thereafter, on how to complete and document medication and medical record checks.
6. How will we monitor to prevent reoccurrence? Include specific record-keeping, ongoing monitoring activities and action plan follow-up.
Operation Manager will ensure that all daily medication and medical record checks are completed, and the forms are completed thoroughly and accurately. |
10/02/2020
| Implemented |