| 6400.62(a) | The bathrooms in the home contained antibacterial soap that stated to contact poison control if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1. A plan to fix the immediate problem:
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future.
The House Manager is responsible for purchasing the cleaning supplies for each home. A meeting was held with the House Manager responsible for overseeing all operations of the home including purchasing the cleaning supplies on 12/19/2024. On the same day before the inspectors left, the Manager purchased hand soap and replaced both bathrooms with the correct soap. Going forward, the House Manager will make sure that all hand soap purchased for the homes is not antibacterial soap. Should individuals' teams feel that an individual is able to use poisons safely, a team meeting will be held, and the ISP¿s will be revised to reflect the changes. The Program Specialist will be responsible to ensure the changes are reflected on the ISP should changes be deemed necessary.
b. WHAT will be corrected:
The soaps that were in the bathroom were antibacterial hand soap. They were replaced with regular hand soap. (images attached)
c. WHEN the correction will be completed?
The soaps were replaced on 2/19/2025 and ongoing thereafter.
d. HOW (usually attached as procedure)
The poisonous soaps were replaced by physically removing them from the bathrooms and from the home and replacing them with regular soaps that were purchased on the same day and ongoing thereafter.
2. The POC must address the exact violation(s) that were cited in the LIS.
The exact Violation was 55 PA Code Chapter 6400.62(a)
3. Since ODP measures compliance based on samples, providers must indicate a review of all resident or staff records to determine if any others are out of compliance and need to be corrected.
This soap violation was only found in one home. A review of the 2nd home by the licensors on 2/19/24 showed compliance. All other upcoming homes that are operated by CCS will have regular soap and not antibacterial soap that requires staff to contact poison control if ingested.
4. Target dates for completion of each step.
This was completed on 12/19/2024 and ongoing. (See images)
5. Specific dates by which correction tasks will be completed are required to effectively monitor plan completion.
The non-poisonous soap that was specific to this location was corrected on 12/19/24. No other CCS home had this violation. |
12/19/2024
| Implemented |
| 6400.32(r) | Individual Rights for individual #1 signed upon admission missing statements regarding locks. | An individual has the right to lock the individual's bedroom door. | 1. A plan to fix the immediate problem:
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future.
The CCS CEO and the CCS Director.
b. WHAT will be corrected
The Individual Rights Packet is missing the statement that individual has the right to lock the individual's bedroom door.
c. WHEN the correction will be completed?
The Rights packed was revised on 12/23/2024. It was reviewed with all individuals on 12/30/24 and signatures were obtained. (see attachment #6)
d. HOW (usually attached as procedure)
The CEO took the Individual Rights section or the 6400 regulations and ensured that all items listed on the regulations were included. (See attachment #4)
2. The POC must address the exact violation(s) that were cited in the LIS.
The exact violation was 55 PA Code Chapter 6400.32(r)
3. Since ODP measures compliance based on samples, providers must indicate a review of all resident or staff records to determine if any others are out of compliance and need to be corrected.
All records were updated and reviewed with the individual and their team.
4. Target dates for completion of each step.
The Rights packet was revised on 12/23/2024 and was reviewed and presented to all individuals served though CCS for signatures. All packets were signed and filed in individual files by 12/30/2024.
5. Specific dates by which correction tasks will be completed are required to effectively monitor plan completion.
The Rights packet was revised on 12/23/2024 and was reviewed and presented to all individuals served though CCS for signatures. All packets were signed and filed in individual files by 12/30/2024. |
12/30/2024
| Implemented |