| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(d) | Staff Members 1 and 2's initial criminal background checks were not retained. Hired in April and June 2023 respectively, their checks were redone in August 2023, and that is what is captured in their files. | A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
| Health1st record-keeping unit files all essential documents, including employees¿ State Police and FBI reports, immediately after receiving them. Since the Licensing Survey Visit on 8/30/23, the agency record-keeping unit has implemented a redundant checklist system. Two staff will check new employee files to ensure all required hiring documents are appropriately filed. Education and training about compliance with 55 PA Code Chapter 6400.21(d), underscoring the imperative to file hiring documents appropriately, was completed with record-keeping staff on 8/30/23. |
08/30/2023
| Implemented |
| 6400.141(c)(14) | Individual 1's 10/21/22 physical does not contain medical information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Health1st promotes individual health and well-being through preventive, routine, and sick health visits with physicians and non-physician providers, including supporting individuals to complete annual physical examinations. The medical examination of the individual in question was completed annually per regulation. Individual physicians have the authority to determine what information is pertinent and how they choose to share pertinent information on the ¿Annual Physical Examination Form (APEF).¿ The citation in question queries why the physician did NOT complete the Allergies /Sensitivities section of the 2022 APEF. It must be noted that the individual physician has the authority to complete the APEF in a way that they understand to be the most appropriate to share information among the interprofessional care team members to ensure individual clients¿ safety. On the 2022 APEF, the physician did not list specific allergies but documented two contraindicated medications below the allergies/sensitive line on the form, which Health1st understood as a medical professional decision. It will NOT be ideal for Helath1st to override the physician's determination to leave the allergies/sensitive section blank but draw readers' attention to review the contraindicated medications should there be an emergency. Health1st will continue encouraging Physicians to complete the APEF thoroughly but will NOT be able to override or alter their documentation. |
08/30/2023
| Implemented |
| 6400.142(c) | Individual 1's 7/13/23 dental visit documentation does not contain a record of procedures completed. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | Health1st promotes individual health and well-being through preventive, routine, and sick health visits to specialists, including Dentists. The dentist completed a dental visit that thoroughly documented the individual dental health and hygiene in 2022, with a recommendation for a follow-up visit in the Summer of 2023, completed on July 13, 2023. The dentist did not include new details in his written report but verbally informed the consumer and staff that his dental hygiene was satisfactory. Nonetheless, following the 8/21/23 licensing site survey, Health1st instituted an ¿Individual Specialist Visit Form¿ for Direct Service Professionals (DSPs) to take to each specialist visit to be completed by the specialist provider. The goal is to facilitate detailed documentation of what transpired at each visit and document information about procedures or treatments completed and/or recommended at the visit. On 8/30/23, education and training about complying with 55 PA Code Chapter 6400.142(c) emphasized the imperative for DSPs to take the Individual Specialist Visit Form to each specialist appointment visit for completion. |
08/30/2023
| Implemented |
| 6400.142(f) | Individual 1's record does not contain a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Health1st supports each individual to maintain excellent oral care by providing necessary support in performing dental hygiene procedures and scheduling and keeping routine dental appointments. During the 8/21/23 licensing visit, an individual did not have a dental hygiene plan (DHP) that outlined support needs. , The dentist has documented that his dental hygiene is optimal. Nonetheless, it is necessary to outline a DHP or have the interdisciplinary team document that the individual has achieved dental hygiene independence in writing. For this reason, Healh1st has instituted a corrective action by developing a DHP form to be used as a standard to individualize each consumer DHP. |
08/30/2023
| Implemented |
| 6400.181(e)(10) | Individual 1's record does not contain a lifetime medical document. | The assessment must include the following information: A lifetime medical history. | Health1st maintains a robust record-keeping process to includes a comprehensive health history and individual encounters with the healthcare delivery system. However, none of these documents were labeled Lifetime Medical History (LMH). Following the 8/21/23 licensing survey visit, Health1st combined the comprehensive health history and individual encounters reports into a living document, the LMH, to comply with 55 PA Code Chapter 6400.181(e)(10). Health1st has generated an LMH template and completed an LMH for the individual |
08/30/2023
| Implemented |
| 6400.181(e)(12) | Individual 1's 8/10/23 assessment does not contain recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Health1st assesses supported individuals annually and at any time there is a significant change in condition /status. As appropriate, findings and recommendations are shared with the support coordinator, the entire team, and stakeholders. Following the 8/21/23 licensing visit, it was determined that Health1st also needs to include recommendations on the assessment form where assessment findings are reported to comply with 55 PA Code Chapter 6400.181(e)(12). Health1st has added a recommendation section to the Health1st assessment template to facilitate the inclusion of the recommendations on the same form where assessment findings are reported |
08/30/2023
| Implemented |
| 6400.163(a) | Individual 1's medication Lacosamiln 100 mg was inside of individual 1's medication bin unlabeled. The bottle did not have a prescription label from the pharmacy affixed to the medication bottle. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | At Health1st, Registered Nurses (RNs) primarily administer individual medications and understand the five rights of medication administration, including measures necessary for safe medication administration. Nurses understand that prescription and nonprescription medications must remain in their original labeled containers. The medication in question, LACOSAMIDE 100 mg, was found in its original bottle during the 8/21/23 licensing survey. Following the 8/21/23 licensing survey, Health1st nurses decided that all medication picked from the pharmacy must have additional labeling stuck to each medication bottle, even if the medication is in a factory-labeled bottle. The pharmacist had only placed the labeling on one of 3 bottles of the same medication as in this case. This corrected process will assist in ensuring compliance with 55 PA Code Chapter 6400.163(a) |
08/30/2023
| Implemented |