| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff Person #3 was hired on 12/29/23 and a Criminal background check was not requested until 4/16/2024. | 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.
| Martha's way failed to obtained the criminal history record for staff #3.
On 5/14/24 Martha's Way human resource department was reeducated on the regulations and compliance of obtaining criminal history clearance prior to the date of hire. |
| Implemented |
| 6400.112(e) | Review of fire drill logs does not indicate at least one sleep drill occurred in the past six months. The drill conducted 5/13/24 was done at 10am. 4/14/24 -- 1:34pm, 3/14/24 -- 2:10pm, 2/4/24 -- 9:25am, 1/4/24 -- 5pm, 12/4/23 -- 8:32am, 11/4/23 -- 7:40pm, 10/14/23 -- 11:12pm. | A fire drill shall be held during sleeping hours at least every 6 months. | Martha's Way failed to note on the fire drill form on 10/14/23 that this was an overnight drill as the individual was asleep in the home.
Martha's Way house supervisor and staff was reeducated on how to properly document an overnight asleep fire drill. |
05/28/2024
| Implemented |
| 6400.141(c)(10) | No record of completion of annual physical for individual #3 stating they are free from communicable diseases. According to the ISP, the last physical was completed 11/17/2022. | 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. | Martha's Way failed to obtain a copy of individual #3 physical exam form prior to admission.
Individual #3 annual physical exam was completed on 04/11/2024. |
05/30/2024
| Implemented |
| 6400.181(a) | No record of initial assessment completed a year prior to admission or 60 days within of admission for Individual #3. The only item provided was an ISP with a print date of 9/7/2023. The document combines details from 2020. She entered the home in 10/2023. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The program specialist failed to place a hard copy of individual #3 initial assessment in their record.
On 5/15/24, a hard copy of individual # 3 initial assessment was placed in individual's file kept in the home.
The program specialist was reeducated by the CEO on the filing system of individual's records kept in the home. |
05/15/2024
| Implemented |
| 6400.165(e) | The following prescription for Individual #3 was not available. Lithium Carb Tab 300 MG ER -- Take 1 tab twice a day was not found with during medication review. Staff stated that it was discontinued, however the medication does not reflection discontinuation on the MAR. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | Marthas Way failed to discontinued the individual #3 Lithium Carb Tab 300 MG ER on the medication record.
On 5/14/24, the House Supervisor discontined individual #3 Lithium Carb Tab 300 MG ER on the medication record. On 4/12/24 individual #3 Lithium Carb Tab 300 MG ER was discontinued by the CRNP. |
05/14/2024
| Implemented |
| 6400.165(g) | No record of quarterly reviews for medications prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician documenting the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Only one document from 9/2023 found in the record meets the criteria for Individual #3. | 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. | The new house supervisor failed to take along to the quarterly psychotropic medications reviews appointments the agency's psych med review form.
On 3/5/24, individual #3 had a medication review of her psychotropic medication by the UPMC Cedar emergency room department during a visit. On 5/22/24 individual #3 had a medication review of her psychotropic medications.
On 5/15/24, the house supervisor and staff was reeducated on the use of the agency's standard quarterly psychotropic medication review form as well as the completion of the form. |
05/30/2024
| Implemented |
| 6400.183(c) | No list of persons who participated in the last individual plan team meeting was found on file for Individual #3. | The list of persons who participated in the individual plan meeting shall be kept. | Martha's Way program specialist failed to obtain a copy of the individual #3 ISP signature sheet.
On 5/15/24, Martha's Way CEO obtained a copy of individual #3 ISP signature from the SC and placed a copy in the record. |
05/30/2024
| Implemented |
| 6400.213(1)(i) | The file for Individual #3 is missing documentation of hair color, eye color and identifying remarks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Martha's Way agency's individual demographic form failed to contain information to record an individuals hair color, eye color and identifying marks.
On 5/14/24 Martha's Way revised the individual's demographic form to include hair color, eye color and identifying marks. Individual #3 demographic form was completed on the new form to contain the missing identification information. The house supervisor removed all old paper versions of the demographic form from the home. |
05/28/2024
| Implemented |