| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was a poisonous hand sanitizer in the kitchen that was locked up during the inspection. The closet where the poisons substances are held was not locked. The closet was locked during the inspection. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The storage closet containing poisonous hand sanitizer was immediately secured with a lock at the time of inspection. All other chemical storage areas were audited to ensure they remain locked and inaccessible. |
06/25/2025
| Implemented |
| 6400.68(b) | Water temperature for bathtub got up to 123°F | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water heater thermostat was immediately adjusted to ensure the maximum temperature does not exceed 120°F. Maintenance staff verified the adjustment using a calibrated thermometer. A follow-up check was performed to confirm that all bathtubs and showers temperatures were within the acceptable range. |
06/25/2025
| Implemented |
| 6400.104 | For Individual #2: A letter to the Fire Department is not on record. The letter provided was sent to the Police Department which operates from a different address. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A New fire letter was drafted and delivered to the local fire department with address, resident name, and bedroom location. A File copy was placed in the emergency binder. |
06/25/2025
| Implemented |
| 6400.113(a) | Individual #2 was admitted to the program on 3/1/25, and fire safety training did not occur until the day after admission on 3/2/25, and this should have occurred prior to or on the day of admission. | 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. | Individual #2 received fire training the day after admission due to staff oversight. Policy now mandates training be completed before bed assignment. Staff was retrained on same-day requirement. |
06/25/2025
| Implemented |
| 6400.141(c)(6) | Individual #2 record does not include record of TB screening. PA DOH Immunization records, Lifetime Medical History, current physical, and other medical records did not contain any information related to TB screening. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | A TB test was conducted for Individual #2 by 6/07/2025 and documented results have been placed in their medical record.
We Reviewed all resident medical records to ensure TB screening compliance. |
06/25/2025
| Implemented |
| 6400.143(a) | Individual #2 frequently refuses medication; however, the refusals and continued attempts to train the individual about the need for health care was not documented in the individual's record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | All medication refusals and corresponding health education attempts for Individual #2 were documented retroactively in their file. Staff were retrained on documenting refusals and health discussions. |
06/25/2025
| Implemented |
| 6400.144 | Individual #2: Lifetime Medical History and ER paperwork refers to a scheduled 4/7/25 gynecology appointment at Women's Health and Gynecology in Darby; however, there is no record to show if this appointment was completed or if the individual refused treatment. When requested, the paperwork provided refers to a 4/17/25 appointment that was not referenced in the individual's file. | 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.
| It was discovered that the individual missed the GYN appointment. Contact was made with the Women¿s Health and Gynecology office to reconfirm appointment for 07/15/2025. Updated documentation has been added to Individual #2¿s file |
07/15/2025
| Implemented |
| 6400.18(a)(3) | Individual #2: Incident 9628204(BH Crisis) was initiated on 5/20/25, and the initial section has not been submitted. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital.
| The Program Specialist submitted the initial section of Incident #9628204 (BH Crisis) for Individual #2 immediately upon notice of the oversight. Retraining was provided to all relevant staff on timely incident initiation and submission through the HCSIS system within the required 24-hour window. |
06/25/2025
| Implemented |
| 6400.18(i) | Individual #2: - Incident 9611852 (Physical Abuse) was due on 5/27/25 and has not been extended - Incident 9628232 (Missing Individual) was due on 5/25/25 and has not been extended - Incident 9605349 (BH Crisis) was due on 5/16/25 and has not been extended - Incident 9599739 (BH crisis; not approved by county) was due on 5/11/25 and has not been extended - Incident 9628222 (Missing Individual) was due on 5/26/25 and has not been extended
6400.113(a)
Ind. Trained Individual #2 was admitted to the program on 3/1/25, and fire safety | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | All listed incidents were reviewed, and formal extension requests have been submitted where applicable. Staff involved have been coached on the policy requiring submission of extension requests prior to the 30-day deadline. |
06/25/2025
| Implemented |
| 6400.163(h) | PRN Ibuprofen 200 mg was in with individual #2 medications but was not on the MAR | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | PRN Ibuprofen was immediately removed and destroyed per policy. A review confirmed it was not documented on the MAR. Staff involved received retraining on proper medication documentation and disposal procedures. |
06/25/2025
| Implemented |
| 6400.166(a)(11) | Except for the PRN medications the diagnosis or purpose for the medication was not on the MAR for individual #2 | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The diagnosis for all medications administered to Individual #2 was updated on the MAR. The nurse reviewed all current MARs to ensure compliance. |
06/25/2025
| Implemented |
| 6400.166(b) | The medication Quetiapine 100 mg had a dose for 05/03/25 missing in the blister pack but was not signed off on the MAR for individual #2 | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The missing signature for Quetiapine on 5/3/25 was noted, and the responsible staff member was counseled and re-educated. Medication count sheets and administration times were reviewed to confirm the dose was in fact given. |
06/25/2025
| Implemented |