| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Kitchen cabinet under the sink is missing the knob. | Floors, walls, ceilings and other surfaces shall be in good repair. | Direct care Staff and the program coordinator were retrained on the importance of checking that all floors walls and ceilings and other surfaces are in good repair and what to do if those areas are found in non-compliance. The landlords were contacted by the program coordinator and informed of the missing knob and per their availability are scheduled to come out the home by June 16th to fix the knob at the home. |
06/16/2023
| Implemented |
| 6400.143(b) | Medication CULTURELLE PROBIOTIC is being administered to individual #1 without a written prescription. This medication is being signed as administered but the medication was not present in the home during inspection on 04/13/2023. | If an individual has a serious medical or dental condition, reasonable efforts shall be made to obtain consent from the individual or substitute consent in accordance with applicable law. See section 417 of the Mental Health and Intellectual Disability Act of 1966 (50 P. S. § 4417(c)). | The direct care staff and program coordinator were retrained on the importance of ensuring that if an individual If an individual has a serious medical or dental condition, reasonable efforts shall be made to obtain consent from the individual or substitute consent in accordance with applicable law. See section 417 of the Mental Health and Intellectual Disability Act of 1966 (50 P. S. § 4417(c)). the medication was reordered for individual #1 and made available to them. Staff had a refresher on the steps of the medication process and what to do if a medication is not available and steps to take for reordering. The program coordinator was also retrained on the home biweekly checklist and the importance of utilizing it to ensure health and safety of our Indvidual's within the homes. |
06/09/2023
| Implemented |
| 6400.144 | PRN medication(s) are listed on the individual #1's medication administration record but was not physically at the home. DIAPER RASH OINTMENT 40%, RA BISACOBYL EC 5mg, COUGH DM POL MG/5mg, AIRBORNE CHEW, GLYCERIN 99.5% LIQ, CLORTRIMOZOLE CREAM 1%, FLEET BISACODYL 10mg, CLONATE 1mg, CALC ANTACID 500mg CHEW. | 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.
| The direct care staff & program coordinator were retrained on the importance of ensuring that if 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. The prn medication was reviewed by his doctor and updated scripts completed and PRN medications were reordered for individual #1 and made available to them. Staff had a refresher on the steps of the medication process and what to do if a medication (prn or regular) is not available and steps to take for reordering as well as the importance of PRN medications and why they have to be onsite as prescribed. The program coordinator was also retrained on the home biweekly checklist and the importance of utilizing it to ensure health and safety of our Indvidual's within the homes especially as it pertains to med checks. |
06/09/2023
| Implemented |
| 6400.162(a) | Medication 60 BILLION PROBIOTIC is listed on the individual #1's medication administration record, however this medication was not prescribed by a licensed physician. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | The direct care staff & program coordinator were retrained on the importance of ensuring that if A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. The current medication was reviewed by his doctor and updated scripts completed and meds were reordered for individual #1 and made available to them. Staff had a refresher on the steps of the medication process and what to do if a medication (prn or regular) is not available and steps to take for reordering as well as the importance of medications and why they have to be onsite as prescribed. The program coordinator was also retrained on the home biweekly checklist and the importance of utilizing it to ensure health and safety of our Indvidual's within the homes especially as it pertains to med checks. |
06/09/2023
| Implemented |