| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | There was no access to a locked closet. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | On the day of the inspection, access to a locked closet was temporarily unavailable due to a misplaced key. The closet was unlocked later that day, and all contents were reviewed. A secondary labeled key was added to the master key set immediately. |
06/25/2025
| Implemented |
| 6400.21(a) | Staff #1 (4/14/2025 Staff person's criminal history background check completed 5/20/2025. (4/14/2025 -- Staff person's criminal history background check completed 5/20/2025
New Hires Staff #3 -- Staff person was hired on 2/20/2025. Criminal history background check not completed until 5/20/2025. Staff #4-- Staff person was hired on 3/5/2025/ Criminal history background check not completed until 4/29/2025. Staff # 5 person was hired on 2/18/2025. Criminal history check on file dated 5/2/2023. Staff person# 6 was hired on 2/21/2025. Criminal history background check not completed until 4/8/2025. - Staff person #7 was hired on 2/28/2025. Criminal history background check not completed until 4/8/2025.
Staff person #8 was hired on 1/29/2025. Criminal history background check not completed until 4/8/2025. No background check on file. Staff person #9 hired 2/21/2025. Staff person #13 was hired on 2/21/2025. Criminal history background check not completed until 3/5/2025. No background check on file. Staff person#10 hired 2/21/2025. Staff person #11 was hired on 3/10/2025. Criminal history background check not completed until 4/8/2025. -- No background check on file. Staff person# 12 hired 11/18/2024. | 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.
| Criminal background checks for all listed staff were immediately submitted and filed. All staff who had delayed checks were temporarily removed from direct care responsibilities until compliance was verified. |
06/25/2025
| Implemented |
| 6400.110(a) | The smoke detector was inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The defective smoke detector was immediately replaced and tested to confirm operability on the day of the inspection. |
06/25/2025
| Implemented |
| 6400.112(c) | Fire drill conducted 4/13/2025 does not capture the length of time of the drill. Fire drill conducted 3/13/2025 does not capture the length of time of the drill. Fire drill conducted 2/13/2025 does not capture the length of time of the drill. Fire drill conducted 9/13/2024 does not capture the length of time of the drill. Fire drill conducted 8/13/2024 does not capture the length of time of the drill | 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. | All affected fire drill records were updated with estimated evacuation times where available. Staff were re-trained on how to document drills correctly. |
06/25/2025
| Implemented |
| 6400.113(a) | Fire safety training 6400.113 fire safety signed on 06/14/25 instead of admission date of 06/13/24 | 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. | The individual completed fire safety training on 6/14/24, one day late. The training was repeated and documented on 6/10/2025 as a refresher. |
06/25/2025
| Implemented |
| 6400.141(a) | No Pre-admission physical. 6400.141A. Most recent physical was 10/2024 after admission | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The individual¿s physical, dated October 2024, was completed post-admission. A new exam was scheduled and completed on 6/1/2025 to reset compliance. |
06/25/2025
| Implemented |
| 6400.151(a) | No physical found on file for staff person prior to hire date of 12/26/2023. | 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. | The staff person¿s physical was not completed prior to the 12/26/2023 hire date. The staff person was re-examined and documentation was filed on 6/3/2025. |
06/25/2025
| Implemented |
| 6400.34(a) | Admission date of 06/13/24 but individual rights signed on 06/14/24 citation 6400.34A | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual rights were signed on 6/14/24, one day after admission. The document has been re-reviewed and signed again with updated explanation. |
06/24/2025
| Implemented |
| 6400.163(a) | Individual #1 had medications in a pill organizer instead of its pharmacy labeled package | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | All medications for Individual #1 were removed from the pill organizer and returned to original pharmacy containers. The nurse verified label accuracy. |
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 #1 | 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. | Diagnoses and purposes for all medications were added to the MAR for Individual #1. A cross-check was done against the physician¿s orders. |
06/25/2025
| Implemented |
| 6400.167(a)(1) | The medication Amphet/Dextr ER 25 mg for individual #1 was signed off on the MAR May 2, 2025, through May 6, 2025; however, the medications were in the blister pack for those dates. The medication Cetirizine 10 mg's pharmacy label states to take daily for 14 days and the medication was administered from May 18, 2025, through May 26, 2025, for a total of 9 days for individual #1 | Medication errors include the following: Failure to administer a medication. | The missed doses of Amphet/Dextr ER and under-administration of Cetirizine were investigated. The staff responsible were retrained, and a Medication Error Report was submitted in EIM. |
06/25/2025
| Implemented |
| 6400.167(a)(3) | The medication Benzonatate 200 mg's pharmacy label states to take daily for 7 days and the medication was administered from May 18, 2025, through May 26, 2025, for a total of 9 days for individual #1 | Medication errors include the following: Administration of the wrong dose of medication. | Benzonatate was administered beyond its prescribed 7-day period. The medication was discontinued and disposed of immediately. A retraining on pharmacy labels was conducted. |
06/25/2025
| Implemented |