| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's financial records contained a receipt dated 4/5/17 for $5.30 for KFC however this money was never documented on his/her financial log. According to the financial log staff withdrew $8.00 on 4/4/17 for a day program activity however according to Staff#1 the money was not received by the day program until 4/5/17. Individual #1's financial log indicated $20.00 was subtracted from financials on 4/12/17 but it was not taken out of the account until 4/13/17 for the circus. According to Individual #1's financial log $8.00 was taken out on 6/7/17 however there is no receipt present. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A new role of Team Leader has been created and is in the process of being filled for each residential home in order to complete daily checks of the spending ledgers. This will add more oversight and ensure that direct care staff are documenting the transactions properly. The Team Leader will check the spending ledgers for each home that they are assigned and address any discrepancies immediately. The Team Leaders will then turn the individual spending ledgers in to the Residential Supervisor on a weekly basis. The Residential Supervisor will then do a double check on the accuracy and completeness of the ledgers. After the Residential Supervisor reviews the spending ledgers, she will then turn them in to the Human Resources Manager every month for a third check of the accuracy and completeness of the ledgers. Completion Date of 8/18/2017 |
08/18/2017
| Not Implemented |
| 6400.22(d)(2) | Individual #1's financial record contained two receipts for Batters up baseball each for $35.00. One receipt dated 4/6/17 was documented on the financial log. The other receipt was dated 4/21/17 and was not documented on the financial log. On 4/12/17 Individual #1's financial log indicates that $30.00 was taken out for toiletries however the receipt dated 4/12/17 was only for $27.19. The $2.81 were never added back to the financial log. The financial log for Individual #1 indicated $27.19 was taken out for Dollar General on 4/12/17 but there is no receipt present in the financial record. | (2) Disbursements made to or for the individual.
| A new role of Team Leader has been created and is in the process of being filled for each residential home in order to complete daily checks of the spending ledgers. This will add more oversight and ensure that direct care staff are documenting the transactions properly. The Team Leader will check the spending ledgers for each home that they are assigned and address any discrepancies immediately. The Team Leaders will then turn the individual spending ledgers in to the Residential Supervisor on a weekly basis. The Residential Supervisor will then do a double check on the accuracy and completeness of the ledgers. After the Residential Supervisor reviews the spending ledgers, she will then turn them in to the Human Resources Manager every month for a third check of the accuracy and completeness of the ledgers. Completion Date of 8/18/2017 |
08/18/2017
| Not Implemented |
| 6400.22(e)(2) | Staff gave money directly to Individual #1 on 4/13/17 for $6.00 and 4/5/17 for $8.00 however he/she is assessed to not be able to handle money. The financial records does not indicate that staff are giving money directly to Individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | A new role of Team Leader has been created and is in the process of being filled for each residential home in order to complete daily checks of the spending ledgers. This will add more oversight and ensure that direct care staff are documenting the transactions properly. The Team Leader will check the spending ledgers for each home that they are assigned and address any discrepancies immediately. The Team Leaders will then turn the individual spending ledgers in to the Residential Supervisor on a weekly basis. The Residential Supervisor will then do a double check on the accuracy and completeness of the ledgers. After the Residential Supervisor reviews the spending ledgers, she will then turn them in to the Human Resources Manager every month for a third check of the accuracy and completeness of the ledgers. Completion Date of 8/18/2017
Program Specialists will review each individual¿s ISP/Assessment and make any changes to the documents in order to update the person¿s current money handling abilities. The Team Leaders will then ensure that the proper documentation takes place on the ledgers when giving individuals their own money to handle. |
08/18/2017
| Not Implemented |
| 6400.62(a) | Dawn dish soap was present under the kitchen sink unlocked. Individual #1 and Individual #2 are not safe with poisons. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 6400.62
An email has been sent to Individual #1s support coordinator requesting his ISP be updated to include which poisons he is safe around. (attachment#14) . All other individuals in the home have ISPs that reflect that they are safe around all poisons. Residential supervisor will be responsible to ensure that all poisons which are not listed in the ISP are locked. Residential supervisor/team leader will do daily walk throughs and ensure no poisons are left unlocked. 6/22/17 |
06/22/2017
| Not Implemented |
| 6400.64(a) | There were four bars of soap present in the same container. Individual #3's bedroom smells of urine. | Clean and sanitary conditions shall be maintained in the home. | Individual #3's Residential Supervisor, Beth Zeth will ensure that direct care staff are not providing them with multiple bars of soap unless they are specifically requesting the extra bars. Completion Date of 7/7/2017 Medical Coordinator, Mandi Barnhart is scheduling an appointment with Individual #3's PCP in order to rule out any incontinence issues. Completion Date of 7/14/2017 |
07/14/2017
| Not Implemented |
| 6400.64(e) | No lid was present on the trash receptacle in the basement. | Trash receptacles over 18 inches high shall have lids. | Carol Bartley, (President) purchased a new garbage can with a step lid and Nate Monahan (Maintenance) has placed the new trash can in the basement. John Bartley (Maintenance Supervisor) will do quarterly inspections of each home moving forward and inform Nate Monahan (Maintenance) of any needed repairs. Completion Date of 6/23/2017 |
06/23/2017
| Not Implemented |
| 6400.67(a) | Bottom drawer of the dresser located in the hallway is stuck. The upstairs bathroom drawer is missing a knob. Individual #2's lampshade was broken in his/her bedroom and it was not plugged in. The front screen door does not shut because the door knob is missing. The door knob to Individual #1's bedroom is broken. | Floors, walls, ceilings and other surfaces shall be in good repair. | Nate Monahan (Maintenance) will be addressing the bottom drawer of the dresser that is stuck in the hallway. Nate will do the necessary repairs to free the drawer or replace the dresser if need be. Nate will replace the upstairs bathroom drawer knob that is missing as well. Individual #2's lampshade that was broken will be disposed of since it was property of CSI and a new lamp will be purchased for Individual #2 once she moves to her new residence if one is needed/desired. The front screen door will be inspected by Nate Monahan (Maintenance) and a new door knob will be replaced to restore proper function. Nate Monahan (Maintenance) will be purchasing a new door knob and installing it to Individual #1's bedroom door as well. John Bartley (Maintenance Supervisor) will do quarterly inspections of each home moving forward and inform Nate Monahan (Maintenance) of any needed repairs. Completion Date of 7/7/2017 |
07/07/2017
| Not Implemented |
| 6400.74 | One step leading to the basement is missing a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Nate Monahan (Maintenance) will be replacing the missing nonskid surface that was absent from the basement step. John Bartley (Maintenance Supervisor) will do quarterly inspections of each home moving forward and inform Nate Monahan (Maintenance) of any needed repairs. Completion Date of 7/7/2017 |
07/07/2017
| Not Implemented |
| 6400.76(a) | Closet door in Individual #3's bedroom does not open the entire way. There was lint the size of a golfball in the dryer trap. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Nate Monahan (Maintenance) will inspect Individual #3's closet door and make any required repairs in order for it to fuction properly. John Bartley (Maintenance Supervisor) will do quarterly inspections of each home moving forward and inform Nate Monahan (Maintenance) of any needed repairs. Direct Care staff will be made aware of the need to remove all lint from the dryer trap after each use. Completion Date of 7/7/2017 |
07/07/2017
| Not Implemented |
| 6400.80(a) | There were two bushes overgrown on outside walk way. There was a recycle bin present halfway on the walkway in the back. Weeds were overgrown onto the back steps. One step is currently loose. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | John Bartley (Maintenance Supervisor) has trimmed the two bushes that have overgrown the outside walk way. (Attachment 9) A cement paving stone has been purchased to place the recycle bin on top of so that staff know not to place the bin on the walk way in the future. (Attachment 10) The weeds on the back steps were also trimmed. Completion Date of 6/23/2017
The loose step will be re-secured by Nate Monahan (Maintenance) Completion Date of 7/7/2017 |
07/07/2017
| Not Implemented |
| 6400.80(b) | There was a trash can present under the steps and a bathmat in a bush. There were dead branches all over the picnic table, an empty box in the backyard and a trash can lid in the backyard. Old wires present on side pavement. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | John Bartley (Maintenance Supervisor) has removed the trash can that was present under the steps and the bathmat that was present in the bush. The dead branches have also all been removed from the picnic table. The empty box and trash can lid in the backyard have also been removed. The old wires that were found on the side pavement have also been disposed of.
John Bartley (Maintenance Supervisor) will do quarterly inspections of each home moving forward and inform Nate Monahan (Maintenance) of any needed repairs.
Completion Date of 6/23/2017 |
06/23/2017
| Not Implemented |
| 6400.81(g) | Individual #1's bedroom is still a passageway for Individual #2 to use the bathroom. The cot for staff is stored in Individual #2's bedroom. | A bedroom may not be used by other individuals or staff persons as a regular or frequent passageway to another part of the home or to the outdoors. | Individual who was using the bathroom in her housemates room has been removed from the home. The other housemate utilizes the upstairs bathroom. No staff or individuals are permitted to use the bathroom in individuals bedroom. Completion date:6/22/17 |
06/22/2017
| Not Implemented |
| 6400.81(k)(1) | Individual #3's bed was broken in half. | In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. | Individuals bed frame had slipped apart. Maintenance had fixed the bed frame and the bed no longer is broken . (attachment #2). Maintenance will be required to do weekly walk through of the residential homes to ensure that all furniture is in good repair. Any issues noted will be brought to directors attention. A plan to fix issues will be developed and carried out as quickly as possible. Completion date: 6/22/17 |
06/22/2017
| Not Implemented |
| 6400.101 | Key entry to Individual #2 and Individual #3's bedrooms are not affixed and can not be unlocked. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Nate Monahan (Maintenance) will be responsible to install new non-locking door knobs to replace the current locking door knobs that are on both Individual #2 and Individual #3's bedrooms. Completion Date of August 18, 2017 |
08/18/2017
| Not Implemented |
| 6400.112(d) | The fire drill conducted on 3/21/2017 which was a sleep drill had an evacuation time of 7 minutes and 03 seconds recorded. No other fire drill was conducted during this month and no other sleep drill was condcuted. According to Staff#1, Individual #2 is unable to evacuate during sleep drills with in 2 minutes and 30 seconds and has not been able to do so since January of 2017. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | The individual was removed from her current home and placed in a hotel until her new home is licensed and ready for her to move in. The new home is one story and her bedroom is located close to exit. Residential supervisor will be responsible to conduct fire drills monthly and notify director immediately if individuals are unable to exit in allotted time frame. During quarterly record reviews, Compliance manager will ensure all fire drills are completed properly and all individuals exited in time. Completion date 6/22/17 |
08/18/2017
| Not Implemented |
| 6400.141(c)(7) | Individual #1's physical dated 9/20/16 did not include a gynecological examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual 1 will not cooperate during a gynecological pelvic exam. She refuses and is very afraid to get one completed. Health coordinator will review the need and repercussions of refusal with the individual. The health coordinator will continue to educate the individual on the importance of exams. This will occur quarterly and a signed copy of the review with the individual will be in the record. An email has been sent to the individuals supports coordinator requesting that the ISP be updated to reflect the need to educate the individual and the reoccurring refusal for exams. (attachment#7) Completion date: 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.141(c)(8) | Individual #1's physical dated 9/20/16 did not include a mammogram. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual 1 will not cooperate during a mammogram. She refuses and is very afraid to get one completed. Health coordinator will review the need and repercussions of refusal with the individual. The health coordinator will continue to educate the individual on the importance of exams. This will occur quarterly and a signed copy of the review with the individual will be in the record. An email has been sent to the individuals supports coordinator requesting that the ISP be updated to reflect the need to educate the individual and the reoccurring refusal for exams. (attachment #7) Completion date: 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.141(c)(11) | Individual #1's physical dated 9/20/16 did not include as assessment of health maintenance needs, medication regimen and blood work. This section of the physical was left blank. | 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 health coordinator was trained on the components of physical by director on 6/22/17. This training includes all parts of the physical and what is to be included in each section. (attachment #1). The health maintenance section will include needs, recommended bloodwork, and medication regimen. Health coordinator will be responsible to ensure that all areas in the physical are completed and approved by the physician. The compliance specialist will ensure all physicals are complete during his quarterly record reviews. Completion date: 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.141(c)(12) | Individual #1's physical dated 9/20/16 did not include his/her physical limitations. The physical stated he/she had no phyical limitations however this individual has a visual impairment. | The physical examination shall include: Physical limitations of the individual. | The health coordinator was trained on the components of physical by director on 6/22/17. This training includes all parts of the physical and what is to be included in each section. (attachment #1). The physical limitations section will be commented on on all physicals. Health coordinator will be responsible to ensure that all areas in the physical are completed and approved by the physician. The compliance specialist will ensure all physicals are complete during his quarterly record reviews. Completion date: 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical dated 9/20/16 does not include medical information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The health coordinator was trained on the components of physical by director on 6/22/17. This training includes all parts of the physical and what is to be included in each section. (attachment #1). The training covered the section of the physical where information pertinent to the diagnosis in case of emergency are listed. Health coordinator will be responsible to ensure that all areas in the physical are completed and approved by the physician. The compliance specialist will ensure all physicals are complete during his quarterly record reviews. Completion date: 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.141(c)(15) | Individual #1's physical completed on 9/20/16 states under special diet instructions "none". Individual #1's ISP states he/she is a choking risk. | The physical examination shall include:Special instructions for the individual's diet. | The health coordinator was trained on the components of physical by director on 6/22/17. This training includes all parts of the physical and what is to be included in each section. (attachment #1). The Special diet section of the physical will be completed . Health coordinator will be responsible to ensure that all areas in the physical are completed and approved by the physician. The compliance specialist will ensure all physicals are complete during his quarterly record reviews. Completion date: 8/18/17 |
08/18/2017
| Implemented |
| 6400.143(a) | Individual #1 refused a dental examination of his/her gums on 5/15/17 and 5/16/16. There is no documentation of refusal and attempts to train Individual #1 on the importance of dental exams his/her record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual 1 does not cooperate during a dental exams. She will allow the dentist to exam her while standing and holding on to her staff. an email has been sent to the individuals supports coordinator to update the ISP to indicate that the individual prefers to have her dental exam done this way (attachment #7). The dentist signed off that he was able to complete the exam and no further appointments were necessary until her annual appointment. (attachment #8) Program specialist will update the individuals assessment to reflect the modifications needed for the individual during the dental exam. completion date 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.144 | On 2/7/17 at the primary care physician appoinment for Individual #1 he/she was diagnosed with sinusitis and prescribed medication, given a flu shot and told to monitor his/her temperature and call back if there is a fever. There is no documentation present that Individual #1's temperature was monitored as instructed by the doctor. On 8/14/16 Individual #1 went to the emergency room due to choking on a piece of meat. Individual #1 followed up with primary care physician on 8/16/16 after choking incident and it was indicated that the next appointment at the primary care physician was to be on 10/3/16 however the only other appointment form in Individual #1's file was from 2/7/17. Individual #1 attended a Podiatry appointment on 4/16/16 and was to return in 10 weeks. Individual #1 did not return to the Podiatrist until 7/13/16. Individual #1 received a Depo Medrol shot 40 mg into his/her right knee in September of 2016 and could repeat the shot in 3 months. Individual #1 did not return for another shot until 3/17/17. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Health Coordinator will be trained, by director, on follow-up care of individuals. This training will include the need for health services such as medical, dental, nursing, pharmaceutical, dietary, and psychological services. Continuation of care will be stressed in the training. Health coordinator will be responsible to ensure that all follow up appointments are made and attended in the recommended time frame. Any charting or monitoring will be the responsibility of the health coordinator. These tracking forms will be placed in the individuals permanent record. During quarterly record reviews, compliance manger will ensure that all follow-up and recommendations were completed and in the individuals record. 8/18/17 completion date |
08/18/2017
| Not Implemented |
| 6400.161(e) | Individual #1 was prescribed Mobic 7.5 mg as needed and it was to be discontinued July of 2016 when Mobic 15mg once daily was started per Staff#2. However no documentation was found in Individual #1's record that Mobic 7.5 mg was discontinued and the medication is still listed on his/her current medication administration record for May 2017. | Discontinued prescription medications shall be disposed of in a safe manner. | Health Coordinator will be retrained by Medication Administration Trainer on proper disposal of medications. This training will include how to discontinue a medication and how to dispose of the medication. Health Coordinator will then be responsible to notify staff (verbally and in writing) of any discontinued medication. Health Coordinator will also be responsible to discontinue the medication on the MAR. Health Coordinator will the properly dispose of the medication. The compliance specialist will be required to check each individuals medications and MARS to ensure that all medications are discontinued properly and disposed of. Completion Date : 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.162(a) | Individual #1's medication label for Balmex Cream stated "apply topically to affected area as needed for irritation." The word "rectum" was written on the label. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | Health Care coordinator will be retrained on Medication Administration. This training will be the PA DPW training. This training includes that no one can alter the label of any medication. Following successful completion of this training, Health coordinator will be responsible to ensure that no labels are altered. Health Care Coordinator will also be responsible to ensure that Physicians include all pertinent information when prescribing a medication and that the pharmacy prints the label including all information. During quarterly record reviews, Compliance specialist will check all medications and ensure the labels are comprehensive, unaltered and accurate. Completion Date: 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.164(a) | Staff "AB" signed as giving Individual #1's Imodium 2 mg at 2:45 or 3:45 (no am or pm was noted) on 6/4/17 and there is not name matching these initials on the medication signature page. Imodium pill packet for Individual #1 popped and initialed " 6/4/17 345" and "6/4/17 DR" however on the medication administration log it indicates this medication was administered on 6/4/17 and 6/5/17. Current staff initials are not present on medication signature page in the med file of Individual #1. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Residential supervisor will be responsible to update the signature sheet in each MAR. This signature sheet will be kept in the front of each MAR. any new staff will be required to sign the signature sheet after they are medication trained. Residential supervisor will be responsible to ensure all medication administrators signatures are on the sheet and that the sheet is updated. Compliance manager will do quarterly record reviews of all individuals. During these reviews, compliance Manager will be responsible to make sure the signature sheets are current and in the MAR. 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.165 | On 5/7/17 staff did not administer Individual #1's mobic 15 mg once a day medication. | Documentation of medication errors and follow-up action taken shall be kept.
| All current employees will be retrained on the PA DPW Medication Administration. Any newly hired staff will be trained on the PA DPW medication Administration. Beth Zeth or Amanda Barnhart will be responsible to schedule the training and ensure they are completed properly. This training will include the importance of administering the prescribed medication. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. Compliance Specialist will conduct quarterly record reviews, during these reviews he will identify any errors and notify health coordinator. Completion date 8/18/18 |
08/18/2017
| Not Implemented |
| 6400.171 | There were two boxes of Luck Charms cereal open in the cabinets unprotected from contamination. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Staff will be trained on proper and safe food handling and storage. Residential supervisor will be responsible to provide train to all new and current staff. Residential supervisor will do weekly checks to ensure all food is stored properly. Compliance manager will do monthly walk- through of the home to ensure all food is stored properly. Completion date: 8/18/17 |
08/18/2017
| Not Implemented |
| 6400.216(a) | Individual physicals and fire books left out unlocked on top of file cabinet. | An individual's records shall be kept locked when unattended. | Compliance specialist, program specialist, team leader and residential supervisor will be trained on what is included in a fire book. kasey Bradley will be responsible to provide this training. this training will include that no identifying personal information should be in the book. (attachment #6) the book will be left unlocked in case of fire. this will ensure that staff can access the book in an emergency as quickly as possible. completion date 8/18/17 |
08/18/2017
| Not Implemented |