| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no thermometer in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Thermometers have been bought and made available in the house. |
12/21/2017
| Implemented |
| 6400.104 | A letter of notification to the local fire department was not sent. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A notification letter had been sent to the fire department Marshall to inform of the presence of an individual residing in the apartment located at 120 E NIELDS STREET WEST CHESTER PA 19382 who might need assistance in case of fire emergency. |
01/02/2018
| Implemented |
| 6400.112(a) | There was no fire drill held in the month of September 2017. | An unannounced fire drill shall be held at least once a month. | A fire drill schedule had been made available to the house and a monthly checklist had been made available in the house to ensure that procedures are followed. |
01/05/2018
| Implemented |
| 6400.112(e) | Between the period of 12/11/17 and 1/30/17 there was no sleep drill held. | A fire drill shall be held during sleeping hours at least every 6 months. | Staff had been retrained on the importance of the fire drill (sleep fire drill) and the monthly checklist will serve as a reminder of any procedure needed to be completed. |
01/06/2018
| Implemented |
| 6400.112(h) | On 12/11/17 and 11/8/17 the designated meeting place was left blank. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | An update to the document had been done properly indicating a meeting place outside the building during the fire drill and staff had been trained to recognize the safe spot. |
01/06/2018
| Implemented |
| 6400.141(c)(3) | Individual #1's physical dated 5/11/17 did not list immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The Individual's physical form had been sent back to the PCP for update of information.
A new physical form highlighting the areas of important information needed had been elaborated and staff have been trained to understand what to look for and request after a physical visit at the PCP. |
12/27/2017
| Implemented |
| 6400.141(c)(11) | Individual #1's physical dated 5/11/17 did not include health maintenance needs, medications regimen, and need for blood work. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Individual's physical form had been sent to the PCP for update of information.
Also will be done a follow up on paperwork after each doctor's appointment. |
12/27/2017
| Implemented |
| 6400.141(c)(12) | Individual #1's physical dated 5/11/17 did not list physical limitations. | The physical examination shall include: Physical limitations of the individual. | Individual's physical forms have been sent to the PCP for update of information and a follow up action will be taken after each doctor visit. |
12/27/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's physical dated 5/11/17 did not include the diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual's document had been updated providing the missing information and going forward, a follow up action on the paperwork will conducted after the doctor's visit. |
12/27/2017
| Implemented |
| 6400.141(c)(15) | Individual #1's physical dated 5/11/17 did not include instructions for the individual diet. | The physical examination shall include:Special instructions for the individual's diet. | Individuals document had been updated to indicate any specific diet. |
12/27/2017
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment dated 9/20/17 did not include recommendations for specific areas of training. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | An update to the document had been made indicating the specific areas of training, programming and services. |
01/02/2018
| Implemented |
| 6400.186(b) | Individual #1's ISP reviews were not signed. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | All staff have been retrained on ISP review. |
01/06/2018
| Implemented |
| 6400.186(c)(1) | Individual #1's monthlies were not available for review. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | Program specialist worked to elaborate monthly reviews showing his progress toward ISP outcomes. |
01/10/2018
| Implemented |