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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-Assessment completed does not include the dates that the assessment started and began. | 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.
| Dignity and Respect Homes annual inspection was held on April 30th to May 1st 2024. After the inspection Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 15(a) Self-Assessment completed did not include the dates that the assessment started and began.
Dignity & Respect Homes will ensure that all assessments are properly and entirely completed within 3 to 6 months prior to the expiration date of our certificate of compliance.
Dignity & Respect Homes program specialist will ensure that the Self-Assessment form is properly and entirely completed within 3 to 6 months prior to the expiration date of our certificate of compliance. The program specialist will ensure that self-Assessment includes all the requested documents as well as the dates the assessment started. |
05/06/2024
| Implemented |
| 6400.82(f) | Bathroom on the first floor, attached to a spare bedroom does not have a trash receptacle. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | April 30th to May 1st 2024 Dignity and Respect Home held its 2024 annual inspection. After the inspection, Dignity and Respect homes was in violation of 55 PA Code Chapter 6400. 82(f) bathroom on the first floor, attached to a spare bedroom does not have a trash receptacle.
Dignity and Respect Home placed a trash receptacle in the bathroom on the first floor, attached to a spare bedroom. |
05/03/2024
| Implemented |
| 6400.141(c)(10) | Individual #1's date of admission is 8/31/2023. The physical exam completed on 8/23/23 (prior to admission) does not include documentation if the Individual has any communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Dignity and Respect Home¿s annual inspection was held on April 30th to May 1st 2024. After the inspection Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.141 (c)(10) Individual #1's date of admission is 8/31/2023. The physical exam completed on 8/23/23 (prior to admission) does not include documentation if the Individual has any communicable diseases.
Physical examination is the pillar of diagnostic evaluation, it allows doctors to confirm the diagnosis that is suspected on the basis of the history without any additional expenditure. Communicable diseases is one of those diagnoses that will help to prevent spread of the disease to other individuals presenting in our agency.
Dignity & Respect Home will ensure that all new admissions to the agencies have a physical examination completed prior to admission and will ensure that all fields on the form are properly filled out. Dignity and Respect Homes will ensure the physical examination form includes the sections stating that the individual is free from any communicable diseases. |
05/08/2024
| Implemented |
| 6400.141(c)(12) | Individual #1's date of admission is 8/31/2023. The physical exam completed on 8/23/23 (prior to admission) does not include if they have any physical limitations. | The physical examination shall include: Physical limitations of the individual. | April 30th to May 1st 2024 Dignity and Respect Home held its 2024 annual inspection. After the inspection, Dignity and Respect homes was in violation of 55 PA Code Chapter 6400. 141(c)(12)
Individual #1's date of admission is 8/31/2023. The physical exam completed on 8/23/23 (prior to admission) does not include if they have any physical limitations.
Dignity and Respect Homes understands that the individuals¿ physical limitations help to identify the individual¿s functional limitations and where might need assistance after admission.
Dignity & Respect's Home Plan of correction to stay in compliance and avoid violation from reoccurrence is by making sure that all new admission to its agencies, complete the proper physical examination which includes the individual physical limitations.
Dignity and Respect¿s Program specialist is responsible to make sure that the agency physical examination form includes the individual¿s physical limitations |
05/09/2024
| Implemented |
| 6400.141(c)(15) | Individual #1's date of admission is 8/31/2023. The physical exam completed on 8/23/23 (prior to admission) does not include if they have any special dietary instructions. | The physical examination shall include:Special instructions for the individual's diet. | Dignity and Respect Home¿s annual inspection was held on April 30th to May 1st 2024. After the inspection Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.141 (c)(15) Individual #1's date of admission is 8/31/2023. The physical exam completed on 8/23/23 (prior to admission) does not include if they have any special dietary instructions.
Dignity & Respect understand that an individual's dietary instruction helps to provide advice on what the individual can eat or drink to build a healthy diet. A healthy diet will help to promote healthy growth and development. A healthy diet will help to prevent diet-related chronic disease, and meet nutrient needs
Dignity and Respect¿s plan of corrections is to make sure that every new intake has the proper physical examination which includes dietary instructions. Dignity & Respect Homes Program specialist will ensure that every new intake has the properly completed physical examination form. The physical examination form must include the individual¿s special dietary instructions |
05/09/2024
| Implemented |
| 6400.181(c) | Individual #1's current ISP dated 2/20/2024 states that they are currently on probation, is registered as a sex offender on Megan's Law and has internet usage restrictions. Individual was convicted on 5/30/2023 for sexual abuse of children and they were placed on Megan's Law on 9/6/2023. Individual #1's date of admission was on 8/31/2023. The conviction happened prior to being admitted into the program, however the most recent assessment dated 2/29/2024 does not make any mention that Individual #1 is on probation, is a registered sex offender or has internet usage restrictions. The assessment is not person-specific and has not been created based off interviews, progress notes, and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | April 30th to May 1st 2024, Dignity and Respect held its annual inspection. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 181(c) Individual #1's current assessment did not mention information about individuals¿ criminal records.
Dignity and Respects plan of correction on this violation will be to implement and follow 55 pa Code Chapter 6400.181(c) rules and regulation to stay in compliance. The Program specialist will complete a reevaluation on individual # 1 assessment and include all the missing information including the individuals probation status and individuals restriction of internet usage. |
05/09/2024
| Implemented |
| 6400.181(d) | Individual #1's assessments dated 8/31/23 and 2/29/24 are not signed by the Program Specialist (Staff #1) who wrote the assessment. | The program specialist shall sign and date the assessment. | Dignity and Respect Home¿s annual inspection was held on April 30th to May 1st 2024. After the inspection Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.181(d) Individual #1's assessments dated 8/31/23 and 2/29/24 are not signed by the Program Specialist (Staff #1) who wrote the assessment.
55 PA Code Chapter 6400.181(d) rules and regulation states that the program specialist shall sign and date the assessment before submission. Dignity and Respect¿s plan of correction on this violation will be to implement and follow 55 pa Code Chapter 6400.181(c) rules and regulation to stay in compliance. The Program specialist will complete a reevaluation on individual # 1 assessment and update individual # 1 assessment to include program specialist signature and date of completion of assessment. |
05/09/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's March and January 2024 Medication Administration Record (MAR) lists medication, Symbicort Inhaler. There is no diagnosis or purposes listed for this medication. Individual #1's January 2024 MAR lists medication, Ergocalciferol and Hydroxyzine. There is no diagnosis or purpose listed for these medications. | 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. | Dignity and Respect Home¿s annual inspection was held on April 30th to May 1st 2024. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 166(a)(11) individual #1's March and January 2024 Medication Administration Record (MAR) lists medication, Symbicort Inhaler. There is no diagnosis or purposes listed for this medication. Individual #1's January 2024 MAR lists medication, Ergocalciferol and Hydroxyzine. There is no diagnosis or purpose listed for these medications.
Dignity and Respect understands the importances of the right diagnosis listed on every individual¿s medication MAR. The agency noticed this diagnosis not listed on Individual # 1s MAR and quickly made the correction the next month which was the reason the diagnosis was only listed on Januarys MAR. |
05/09/2024
| Implemented |
| 6400.169(d) | · Staff #2 completed initial medication administration training on 1/5/2021. There is no annual practicum in 2022. Annual practicum was completed again on 8/21/2023. Since Staff #2 did not complete the annual medication practicum in 2022, the initial medication administration course should have been completed. Staff #2 has been administering medications without an up-to date medication administration. Listed are examples of dates that Staff #2 administered medications: Staff #2 administered Benztropine Masylate, Clonazepam, Fluoxetine, Haloperidol, Lansoprazole, Trazodone, to Individual #3 on 3/23/2024. Additionally, Staff #2 administered medications to Individual #3 on 3/22/24 and 3/24/24.
· Staff #4 completed their initial medication administration training on 3/9/2022. There is no dated record of completed annual medication training in 2023. The next dated and recorded annual medication training was completed on 3/1/2024. | 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. | Dignity and Respect Home¿s annual inspection was held on April 30th to May 1st 2024. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 169(d) Staff #2 completed initial medication administration training on 1/5/2021. There is no annual practicum in 2022. Annual practicum was completed again on 8/21/2023. Since Staff #2 did not complete the annual medication practicum in 2022.
Dignity and Respect understand the seriousness of our staff administering medication without the proper credentials. The staff in question had his annual practicum in 2022 and also in 2023. The staff¿s annual practicum was fill out on the wrong form in 2022, the staff in question has all his credentials to administer medication.
Dignity and Respect has registered staff #2 and staff #4 with Temple University to retake the medication administration class all over again to stay in compliance. Initial medication training has been completed.
New certification issued, observations, handwashing and gloving procedures are up to date. |
05/14/2024
| Implemented |
| 6400.182(c) | Individual #1's current ISP date 2/20/2024 identifies their supervision needs as 2 hours a day for home supervision and 6 hours a day for community supervision. The current assessment dated 2/29/2024 states that Individual #1 requires 24-hour supervision and cannot be left alone in the home or community. ISP is not updated based up the Individual's needs. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | April 30th to May 1st 2024, Dignity and Respect held its annual inspection. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 182(c) Individual #1's current ISP date 2/20/2024 identifies their supervision needs as 2 hours a day for home supervision and 6 hours a day for community supervision. The current assessment dated 2/29/2024 states that Individual #1 requires 24-hour supervision and cannot be left alone in the home or community. ISP is not updated based up the Individual's needs.
Dignity and Respect¿s plan of correction on this violation will be to implement and follow 55 pa Code Chapter 6400.182(c) rules and regulation to stay in compliance. Our agencies program specialist will re reevaluate individual # 1 assessment to include all the missing information such as the individual¿s supervision status to reflect that this individual needs 2 hours of home supervision a day and 6 hours of community supervision.
The agency program specialist will email a copy of the revised and corrected assessment to the SC with all the necessary document to stay in compliance |
05/13/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The home needs an all over, every room, deep clean (lights, windowsills, windows, bathroom mirrors, all the floors in every room, all cabinets in kitchen and bathrooms, bathroom sinks, etc.)
There are cobwebs on the kitchen ceiling light fixtures, there is dust and small dead insects on the windowsills in every room, the floors are dirty, the bathroom in the basement has a dirty sink top and a severely dirty shower. The inside of all the kitchen and bathroom cabinets are dirty, and need cleaned out. There are random items being stored in the cabinets throughout the home. (i.e., 2 small wooden doors were detached and being stored in the big pantry in the kitchen. There is a hose and box of supplies being stored in the washing machine in the full bathroom on the 1st floor). There is hair in the vanity cabinets in the 1st floor, full bathroom.
The carpet on the stairs leading to the basement have black stains that appear to be mildew. Recommendation would be to replace the carpet or at least give it a good clean as this contributes to the bad musty smell throughout the home.
The basement has a strong mildew smell which radiates through-out the whole home. | Clean and sanitary conditions shall be maintained in the home. | April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA.
During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 64(a)
The home needs an all over cleaning, every room, deep clean (lights, windowsills, windows, bathroom mirrors, all the floors in every room, all cabinets in kitchen and bathrooms, bathroom sinks, etc.)
Dignity and Respect understands the seriousness of a clean home. Our biggest goals are the health and safety of individuals residing in our homes. The house manager is responsible to make that all part of home is clean and neat at all times. Areas such as individual's bedroom, kitchen, bathroom, basement etc.
Dignity and Respects house staff will hand over a clean shift before relive from duty to help ensure a clean house. |
04/19/2023
| Implemented |
| 6400.66 | There are non-operable lights in the closet beneath the basement stairs, the closet in the basement off the main room, and the closet light in the 2nd bedroom and it also doesn't have a light switch or pull string. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA . During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 66.
There are non-operable lights in the closet beneath the basement stairs, the closet in the basement off the main room, and the closet light in the 2nd bedroom and it also doesn't have a light switch or pull string.
Safety is always a priority in Dignity and Respect. Dignity and Respect understands the important of operable lighting in our individual's closet.
Operable lighting in our closet will help our individuals to identify items in their closets and will also help to prevent injuries. Dignity and Respect's House manager is responsible to make sure that all the lights in the house are operating including all the closet lighting. |
04/18/2023
| Implemented |
| 6400.67(a) | In bedroom #3's, the inside of the closet on the right wall had a hole in the wall approximately 24-inch x 12 inch in size and there were electrical wires visible/exposed due to the hole.
The bottom cabinet to the left of the refrigerator does not have a doorknob on it, there is a hole there, but no knob.
The cabinet to the Right of the refrigerator has one cabinet door that once you open it, it exposes three drawers that pull out, however the middle drawer was missing. | Floors, walls, ceilings and other surfaces shall be in good repair. | April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA . During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 67 (a)
In bedroom #3's, the inside of the closet on the right wall had a hole in the wall approximately 24-inch x 12 inch in size and there were electrical wires visible/exposed due to the hole.
Dignity and Respect understands the seriousness of our individual's safety. Visible hole with exposed wires on the wall is unacceptable. Dignity and Respect's house manager will ensure that all visible holes are covered up immediately to help prevent injuries to individuals and staff members. |
04/26/2023
| Implemented |
| 6400.73(a) | The handrail that was outside the front door and front porch of the home was rusted with peeling paint that has the potential to be hazardous. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA . During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 73 (a)
The handrail that was outside the front door and front porch of the home was rusted with peeling paint that has the potential to be hazardous.
Dignity & Respect understands that rusted and peeling paint anywhere in the house is extremely dangerous. Rusted and peeling paint could lead to lead poisoning which could affect the individuals we serve. Dignity and Respect's maintenance is responsible to check around the house for any rust or peeling paint in order to eliminate any potential hazardous. |
04/28/2023
| Implemented |
| 6400.76(a) | The sink lever on the faucet located on the sink in the second bedroom ensuite bathroom was broken and didn't make the stopper go up or down. | Furniture and equipment shall be nonhazardous, clean and sturdy. | April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA . During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 76 (a)
The sink lever on the faucet located on the sink in the second bedroom bathroom was broken and didn't make the stopper go up or down
Dignity and Respect's maintenance is responsible to repair the bedroom sink faucet in the order to allow water flow probably in the bedroom sink. |
04/18/2023
| Implemented |
| 6400.80(b) | The outside grounds had overgrown grass, weeds along the backyard fence, unkept landscaping, metal garden cones laying in the side yard, a shed that was filled with building supplies and other items and it did not have a door, and loose, falling, and non-secured long white bricks surrounding the basement window on the left side of the home and surrounding the AC unit in the back yard of the home, there were also broken bricks at the top step of the outside stairwell that leads to the basement door. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA . During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 80(b)
The outside grounds had overgrown grass, weeds along the backyard fence, un-kept landscaping , metal garden cones laying in the side yard, a shed that was filled with building supplies and other items and it did not have a door, and loose, falling, and non-secured long white bricks surrounding the basement window on the left side of the home and surrounding the AC unit in the back yard of the home, there were also broken bricks at the top step of the outside stairwell that leads to the basement door.
Dignity and Respect strives to improve the beauty and safety of our property. Unkempt vegetation like weeds, vines and brush makes that nearly impossible. Dignity and Respect understand that vegetation serves as a harborage area for unwanted pests such as rodents, snakes, tick and other critters that can threaten the well-being of our property.
Dignity and Respect's maintenance is responsible to make sure that the house appears neat at all times by regular maintaining the landscaping. Maintenance will be removing any object laying around the property that does not belong such as broken bricks, metal garden cones etc. |
05/02/2023
| Implemented |
| 6400.110(a) | There was no smoke detector in the attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA . During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 110(a)
There was no smoke detector in the attic
Dignity and Respect understands that every minute counts when it comes to a fire. A smoke detector in the attic is critical for an early detection of a fire in our home.
Early fire detection could mean the difference between life and death. Fires can occur in a variety of ways and in any room of the home including the attic, but no matter where or how, having a smoke detector in the attic will help to assure our individuals safety.
Dignity and Respect's maintenance is responsible to make sure that all smoke detectors in the house is up to date and operating probably including the one in the attic.. |
05/05/2023
| Implemented |
| 6400.111(a) | There wasn't a fire extinguisher in the basement or the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | April 17th 2023, Dignity and Respect had an inspection at 1101 Drexel hills Blvd New Cumberland, PA . During the inspection, our agency was in violation for 55 PA Code Chapter 6400. 111(a)
There wasn't a fire extinguisher in the basement or the attic
Dignity and Respect understands the seriousness of not having a fire extinguisher in the basement or the attic. Our agency understands that a fire can start in unexpected location whether its faulty wiring or unattended fire at the kitchen .
fire extinguisher should be on every floor of our home, including the basement and attic. Fires can start anywhere at any time in your home.
Dignity and Respect¿s maintenance is responsible to make sure that each floor of the house has a fire extinguisher including the basement and the attic. |
05/05/2023
| Implemented |
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