| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency provided self-assessments of the home dated 4/10/24. The agency license expires on April 21, 2024. The self-assessments are to be completed within 3-6 months prior to the expiration date of the agency's certificate to measure and record compliance with this chapter. The self-assessments were not completed within the appropriate time frame. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| According to 55 PA Code Chapter 6400.15(a), the self-assessments are to be completed within 3-6 months prior to the expiration date of the agency's certificate to measure and record compliance with this chapter. The self-assessment was provided during the time of inspection which did not adhere to state guidelines. The Provider's Plan of Correction is to retrain their maintence staff on the importance of providing to licensing the self assessment 3 to 6 months prior to the inspection date. |
| Implemented |
| 6400.62(a) | At the time of the inspection there was a large bottle of Ajax degreaser located under the kitchen sink, which was not locked. All poisonous materials shall be kept locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | According to 55 PA Code Chapter 6400.62(a), Poisonous materials shall be kept locked or made inaccessible to individuals. As the Provider's Plan of Correction, every DCW will be retrained on the importance of adhering to regulation 6400.62(a). |
04/30/2024
| Implemented |
| 6400.62(c) | At the time of inspection there was a hand soap located by the kitchen sink. The bottle reflects it was a Suave essentials lemon citrus soap. However, the liquid inside of the bottle was a peach colored liquid and upon opening the bottle there was not a lemon citrus fragrance. Also in the bathroom there was a soft-soap limited edition hooty Halloween hand soap which the bottle reflects was a raspberry vanilla scent. This bottle also contained a peach color liquid and also did not have the specified fragrance the bottle suggested. It appears that both of the soap dispensers had soap refilled that was not the original soap from each container. Poisons shall be stored in their original labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | According to 55 PA Code Chapter 6400.62(a), Poisonous materials shall be stored in their original, labeled containers. The Provider's Plan of Correction are as followed: All DCW will be retrained on the importance of adhering to 6400.62(a), When replacing all hand soaps, all bottles will have their original contents. When refilling, all contents will reflect what the bottle reflects. |
04/30/2023
| Implemented |
| 6400.110(a) | At the time of inspection there was an area off of the kitchen which had steps that led to the attic/crawl space of the home. The agency had a fire extinguisher and smoke alarm at the top of the steps that led to the attic area; however, once opening the ceiling tile to the attic there was no fire extinguisher or smoke alarm in that area. The agency reports that the landlord does not allow them access to that area. It is essential that if the attic is accessible that the fire extinguisher and smoke alarm are in the attic as it is another level of the home. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | According to 55 PA Code Chapter 6400.110(a), A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The Provider's Plan of Correction is to place the fire extinguisher and smokealarm will be place on the attic level with the Landlord's permission. |
04/30/2024
| Implemented |
| 6400.111(a) | At the time of inspection there was an area off of the kitchen which had steps that led to the attic/crawl space of the home. The agency had a fire extinguisher and smoke alarm at the top of the steps that led to the attic area; however, once opening the ceiling tile to the attic there was no fire extinguisher or smoke alarm in that area. The agency reports that the landlord does not allow them access to that area. It is essential that if the attic is accessible that the fire extinguisher and smoke alarm are in the attic as it is another level of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | According to 55 PA Code Chapter 6400.111(a), There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The Provider's Plan of Correction is to place the fire extinguisher and smoke alarm will be place on the attic level with the Landlord's permission. |
04/30/2024
| Implemented |
| 6400.141(c)(13) | Individual #1's annual physical examination dated 6/7/23 did not list any contraindicated medications. That area of the physical was left blank. | The physical examination shall include: Allergies or contraindicated medications. | According to 55 PA Code Chapter 6400.141(c)(13), the physical examination shall include: Allergies or contraindicated medications. The Provider's Plan of Correction are as followed. All individuals upon transitioning to Wisna is required to have a physical that clearly states any contraindicated medications. Although Individual #1 was received with out this information , this must be identified and mediated prior to intake. |
04/30/2024
| Implemented |
| 6400.151(a) | Staff #1 is the CEO and currently filling in as the Program Specialist. Staff #1 did not have a current physical examination on record at the time of inspection. Due to her current status as a Program Specialist that physical is needed every 2 years. | 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. | According to 55 PA Code Chapter 6400.151(a). 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. Staff #1 has completed their annual physical and their file is now compliant with an updated annual physical. |
05/07/2024
| Implemented |
| 6400.32(r)(4) | The individual bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions as expected by this regulation. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | According to 55 PA ode Chapter 6400.32(r)(4), The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. The Provider's Plan of Correction: is to replace the locking mechanism with a keyed lock for easy and immediate action. |
04/30/2023
| Implemented |
| 6400.46(b) | Staff #1 is the CEO and is currently filling in as the Program Specialist. Staff #1 had fire safety training dated 10/15/22 and 3/15/24. There was no fire safety training documented for 2023. Staff shall be trained annually 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). | According to 55 PA Code Chapter 6400.46(b). Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). Staff #1 was trained on the importance of having all fire and safety training in Staff #1's file. Provider's Plan of Correction: The CEO has completed the necessary updates to their file as a Program Specialist. They are now in compliance. |
05/02/2024
| Implemented |
| 6400.51(b)(2) | Staff #2 date of hire was 10/16/23. The staff did not have orientation that encompassed the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the older adults protective services act within the first 30 days of hire. | The orientation 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. | According to PA Code Chapter 6400.51(b)(2), The orientation 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. Provider's Plan of Correction: Staff #2 is now fully in compliance. Their employee files have been updated and the proper documents reflect the complete orientation for compliance. |
05/02/2024
| Implemented |
| 6400.51(b)(3) | Staff #2 date of hire was 10/16/23. The staff did not have orientation that encompassed the individual rights within the first 30 days of hire. | The orientation must encompass the following areas: Individual rights. | According to 55 PA Code Chapter 6400.51(b)(3), The orientation must encompass the following areas: Individual rights. Provider's Plan of Correction: Staff #2 is now in compliance. They have been retrained and their files consist of the missing orientation that encompassed the individual rights within the first 30 days of hire. |
05/02/2024
| Implemented |
| 6400.51(b)(4) | Staff #2's date of hire was 10/16/23. The staff did not have orientation that encompassed recognizing and reporting incidents with in the first 30 days of hire. | The orientation must encompass the following areas: recognizing and reporting incidents. | According to 55 PA Code Chapter 6400.51(b)(4), The orientation must encompass the following areas: recognizing and reporting incidents. Provider's Plan of Correction: Staff #2 has been retained and currently in compliance according to 6400.51(b)(4). Her file now reflects orientation that encompass the following areas: recognizing and reporting incidents. |
05/02/2024
| Implemented |
| 6400.52(b)(1) | Staff #2 date of hire was 10/16/23. The staff did not have orientation that encompassed the applications of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationship within the first 30 days of hire. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | According to 55 PA Code Chapter 6400.52(b)(1), The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. Staff #2 is now in compiance. They have been retrained and their file now reflects completing the 12 hrs of yearly training that encompassed the applications of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationship within the first 30 days of hire. |
05/02/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed several medications to treat symptoms of psychiatric illness. The individual's date of admission to Wisna Serenity was on 7/22/23. The only psychiatric medication review that was provided at the time of inspection was dated 11/21/23. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | According to 55 PA Code Chapter 6400.165(g), If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Provider's Plan of Correction: Every individual has to go through their 90-day Psyc evaluation. While visiting their Pysc Physician, they will be accompanied by a 3-page approved state form. This form will be completed upon their visit. In addition, every individual will also take a 6 mos AIMS test. In the extreme case of an emergency, which may impedes a visit to the Pysc Physician, they will be seen by their PCP and the approved state form will be filled out by their Doctor. |
05/10/2024
| Implemented |
| 6400.166(a)(11) | The medication administration record did not include the diagnosis or purpose for the medication for the following medications: Lexapro, lithium carbonate, loratadine, lorazepam, omeprazole, and paliperidone. | 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. | According to 55 PA Code Chapter 6400.166(a)(11), 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. We are going to reinforce our training on how to perform a proper ¿Monthly Recap¿ of the MAR (Medication Administration Record and Reporting) for our nurses. What that means is before the new month starts, they will look for anything that¿s missing such as proper diagnosis for medications, route of administration, dosage etc¿ If we find any errors, we will then send it to our pharmacy to correct it. Going forward, this training will be added in to their onboarding training for medication administration. This has all been changed since we recently switched from PDC Pharmacy to HomeFree RX. |
05/10/2024
| Implemented |