| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff 10 - there was no FBI clearance check completed, only a child abuse clearance check was done. This staff was hired in September 2022.
Staff 11 - there was no FBI clearance check completed, only a child abuse clearance check was done. | 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.
| Staff person completed the FBI criminal history check on 2/28/23 as instructed by licensing. |
03/31/2023
| Not Accepted |
| 6400.110(e) | The smoke detector in the basement was not interconnected with the first and second floor's smoke detectors at the time of inspection. All smoke detectors functioned during the test but only the second and first floor detectors were interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Embolden will have an electrician check and resolve the issue by the Month's end. |
03/31/2023
| Not Accepted |
| 6400.151(b) | Staff 9 had a physical in the record that was completed in April, but it was not dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff physical is dated and record was sent via email on March 7 2023 |
03/31/2023
| Not Accepted |
| 6400.151(c)(3) | Staff 9 - the physical exam had no statement that indicated whether the staff is free from communicable diseases.
Staff 10 - the physical exam had no statement that indicated whether the staff is free from communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff person signed the Attestation form verifying that they are free of communicable diseases. Physical Form has been revised to include this attestation. |
03/31/2023
| Not Accepted |
| 6400.165(a) | Individual 1 is taking over the counter Vitamin D3 5000 units daily at 6pm, however there is no doctors note or a prescription stating that the individual should be taking this medication. | A prescription medication shall be prescribed in writing by an authorized prescriber. | The standing written order states the following: d. Vitamin D3 5000 IU capsules, take one capsule by mouth daily with her evening meal. Information sent via email on March 7 2023. |
03/31/2023
| Not Accepted |
| 6400.169(d) | Staff 9 - the medication training packet was incomplete as there was no indication that the staff received the 12/10/22 portion of the MAR review. The MAR checklist was not completed. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Staff person MAR review documentation was sent via email on March 7 2023. |
03/31/2023
| Not Accepted |