| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Cannot determine residency greater than 2 years for staff 13 | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Staff PA driver license was issued on 04/2021 and staff was hire in 07/2023 indicating that staff lived in PA greater than 2 years. |
12/22/2023
| Implemented |
| 6400.21(b) | Cannot find criminal history form in file for staff 14 | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Staff provided an FBI fingerprint clearance document that was done on 03/28/2023. |
12/21/2023
| Implemented |
| 6400.64(a) | A soiled urination pad was resting on the couch. | Clean and sanitary conditions shall be maintained in the home. | The soiled urination pad was immediately disposed, and couch was cleaned and sanitized. |
12/21/2023
| Implemented |
| 6400.141(a) | Physical for calendar year 2023 was two months late. Past annual exam completed 11/28/2023 and last physical completed was 8/2022 for individual 2 | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Staff was retrained on the importance of completing individual physical appointments within a year and if it reschedules for any reason, a written doctor note should be provided stating the reason for the rescheduling. |
12/21/2023
| Implemented |
| 6400.151(a) | Most recent physical dated 6.27.2023 was three months late. A new physical should have been completed by 3.8.2023 for staff 3 | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. |
12/21/2023
| Implemented |
| 6400.151(a) | most recent physical dated 7.26.21 is 5 months overdue for staff 1 | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff was retrained and encouraged on the importance of submitting physical form in a timely manner. Staff completed and submitted her physical form on 01/04/2024. |
12/22/2023
| Implemented |
| 6400.151(a) | staff 17 physical completed 18 months before hire. New health evaluations should be completed within 12 prior months of hire. The evaluation was completed six months sooner than what is stipulated by the regulation. for staff 17 | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. |
12/21/2023
| Implemented |
| 6400.151(a) | For Staff 6 there is a physical is dated 11/14/23 but there isn't one for within 12 months prior to employment. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. |
12/21/2023
| Implemented |
| 6400.151(a) | There is no initial physical is on file nor any other physicals on file at all for staff 9 | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff provided a physical examination form completed on which was done on 07/2023. |
12/21/2023
| Implemented |
| 6400.151(c)(2) | Physical Dated 5.30.23 lists TB dated 4.19 which goes beyond the two years required within the initial physical for staff 10 | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff TB test stated negative on physical examination form and an addition testing (chest Xray) was attached at the back of the from indicating it was done and staff was clear. |
12/21/2023
| Implemented |
| 6400.151(c)(2) | Annual physical dated 3.30.23 does not have any notification of TB screening for staff 12 | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff annual physical dated 3/30/2023, the doctor stated, " see x-ray report attached" and the x-ray report was attached at the back. |
12/21/2023
| Implemented |
| 6400.46(a) | Initial Fire Training is dated 6/13/23, yet hire date is 5/30/23. for staff 10 | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. |
12/21/2023
| Implemented |
| 6400.46(a) | Fire Training did not take place until 6/23/23 for staff 12 | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. |
12/21/2023
| Implemented |
| 6400.46(a) | CPR is dated 12/16/22, but no CPR training is on file within the first 6 months after hire for staff 11 | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. |
12/21/2023
| Implemented |
| 6400.46(d) | No CPR/First Aide Training in file for staff 10 | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. Staff file had a CPR certification completed on 06/2022. |
12/21/2023
| Implemented |
| 6400.51(a)(1) | 8/20/23 Orientation was beyond 30 days of hire date for staff 5 | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Management hiring staff has been retrained on the orientation and onboarding process of staff before they are assigned to work in the home. |
12/21/2023
| Implemented |
| 6400.163(a) | Labella Lip balm, Bag Balm Skin Moisterizer, Neosporin, and Aquaphor all were in medication box, but not listed on Medication Administration Log. for individual 2 | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | These medications were immediately removed from the medication box. Staff have been retrained on the storage of medications and on storing medications only listed on the MAR. |
12/21/2023
| Implemented |
| 6400.163(h) | Urea 20% was to be removed from medication box on 9/23. for individual 2 | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Urea 20% was removed from the medication box immediately and staffs were retrained on medication administration and documentation. |
12/21/2023
| Implemented |
| 6400.165(g) | There are only Quarterly psychotropic medication forms on file for June 2023 and September 2023 for individual 2. | 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. | Staff was retrained on medical visit form submission in a timely manner to the MFP for proper filing. A follow up was made to the psych office and the documents are filed. |
12/27/2023
| Implemented |
| 6400.169(a) | No medication practicum provided for staff. Does not include full observations for staff 2 | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff was retrained and now has an updated medication practicum. |
12/23/2023
| Implemented |
| 6400.169(a) | Staff # 15 is not current with medication training. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff was retrained immediately to have his medication administration certificates up to date. |
12/21/2023
| Implemented |