| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace of the home was inspected and cleaned 9/22/21 and then again 11/11/22. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The CFO sent out a memo on 9 February 2023 to his secretary to remind himself and the Sites Operation Manager to schedule maintenance with the Boehmer Heating Company for the Furnaces at the beginning of the new Fiscal Year. |
02/09/2023
| Implemented |
| 6400.141(a) | Individual #2, date of admission 3/1/22, had an initial physical examination completed 7/6/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Annual Physical and TB Test will be completed prior to admission and annually thereafter to comply with PA 55 Code Chapter 6400.141(a). The Site Operations Manager will make sure all Annual Physicals are scheduled and completed to comply with PA 55 Code Chapter 6400.141(a). |
02/10/2023
| Implemented |
| 6400.141(c)(4) | Individual #1's, date of admission 7/27/22, physical examination completed 1/14/22 did not include vision and hearing screenings. Additional documentation was not provided. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Annual Physical Form 34 for CDR Care LLC has spaces for the Vision and Hearing Screening for individuals 18 years of age and older, as recommended by the physician to comply with PA Code Chapter 6400. 141(c)(4). The Site Operations Director before admissions will review the Annual Physical submitted to ensure that all areas of the physical are completed to comply with PA Code Chapter 6400. 141(c)(4). If Annual Physical Documentation is not completed in its entirety to reflect the Vision and Hearing Screening, Site Operations Director will contact Support Coordinator to have Vision and Hearing screening completed prior to admission. |
02/10/2023
| Implemented |
| 6400.141(c)(5) | Individual #2's immunization record does not include verification of a tetanus vaccine ever having been administered. | The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. | The Annual Physical Form 34 for CDR Care LLC has spaces for Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204, also to comply with PA Code Chapter 6400. 141(c)(5). The Site Operations Director before admissions will review the Annual Physical submitted to ensure that all areas of the physical are completed to comply with PA Code Chapter 6400. 141(c)(5). If Annual Physical Documentation is not completed in its entirety to reflect the immunization and screening tests, Site Operations Director will contact Support Coordinator to have Immunizations and screenings tests completed prior to admission. |
02/10/2023
| Implemented |
| 6400.141(c)(6) | Individual #2's physical exanimation completed 7/6/22 did not include a space for the date the Tuberculin skin testing by Mantoux was read. Therefore, compliance could not be measured. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Annual Physical and TB Test will be completed prior to admission and annually thereafter to comply with PA 55 Code Chapter 6400.141(c)(6). The Site Operations Manager will make sure all Annual Physicals are scheduled and completed to comply with PA 55 Code Chapter 6400.141(c)(6). |
02/10/2023
| Implemented |
| 6400.141(c)(8) | Individual #2's, date of admission 3/1/22; date of birth 4/13/1966, record does 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. | The CDR Form 66 Mammogram Record and CDR Annual Physical Form 34 reflects the date of the exam, exam location, results and or follow up to comply with the 6400.141(c)(8) from the 55 PA Code Chapter 6400. The Site Operations Director will make sure that Form 66 Mammogram Records are complete in its entirety upon admissions and biannually thereafter to comply with PA Code Chapter 6400. 141(c)(8).
The Site Operations Director before admissions will review the Mammogram Record submitted to ensure that all areas of the Mammogram Record are completed to comply with PA Code Chapter 6400. 141(c)(8). If Mammogram Record Documentation is not completed in its entirety to reflect the previous and up to date Mammogram screenings, Site Operations Director will contact Support Coordinator to have Mammogram screenings tests completed prior to admission.
In the result of a Participants refusal of this test, the Refusal for Medical Treatment Form 6 will be sent to the Supports Coordinator to have the current agency complete with the Participant. This form will be read, explained, competed and signed by the Participant and a witness stating that the Participant refused tests or medical treatments. |
02/10/2023
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed 1/14/22 did not include an assessment of their health maintenance needs, medication regimen, and the needs for bloodwork at recommended intervals. This section 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 Annual Physical and the health and maintenance needs, medication regimen, and needs for bloodwork at the recommended intervals will be completed prior to admission and annually thereafter to comply with PA 55 Code Chapter 6400.141(c)(11). The Site Operations Manager will make sure all Annual Physicals are scheduled and completed to comply with PA 55 Code Chapter 6400.141(c)(11). |
02/10/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 1/14/22 and Individual #2 physical examination completed 7/6/22 do not include medical information pertinent to treatment and diagnosis in case of an emergency. These sections were left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Annual Physical and the medical information pertinent to treatment and diagnosis in case of an emergency will be completed prior to admission and annually thereafter to comply with PA 55 Code Chapter 6400.141(c)(11). The Site Operations Manager will make sure all Annual Physicals are scheduled and completed to comply with PA 55 Code Chapter 6400.141(c)(14). |
02/10/2023
| Implemented |
| 6400.143(a) | Individual #2's record does not include attempts to train the individual about the need for health care regarding a refused gynecological examination 6/17/22. | 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. | CDR form 6 Refusal of Medical Treatment Form is completed 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 to comply with 55 PA Code Chapter 6400.143(a).
In the result of a Participants refusal of this test, the Refusal for Medical Treatment Form 6 will be completed with the Participant. Site Operations Manager will provide training about the medical treatment, the Refusal Form will be read, explained, competed and signed by the Participant and a witness stating that the Participant refused tests or medical treatments. |
02/10/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's initial assessment completed on 8/26/22 and Individual #2's initial assessment completed on 4/1/22 do not include recommendations for specific areas of training, programming, and services. These sections were left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | CDR Skill Competency / Assessment includes recommendations for specific areas of training, programming, and services to comply with 55 PA Code Chapter 6400.181(e)(12). Upon receipt of the CDR Skill Competency / Assessment the Site Operations Director will review the CDR Skill Competency / Assessment to ensure that all areas of the Assessment are completed in its entirety. |
02/10/2023
| Implemented |
| 6400.165(g) | Individual #2, date of admission 3/1/22, is prescribed Paroxetine tablets 40 mg to treat mental illness. Individual #2 has not had a review by a licensed physician. | 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. | The Psychotropic Medication Review Form 15 will be issued quarterly to licensed physician during the schedule quarterly visit for a medication review to comply with 55 PA Code Chapter 6400.165(g). |
02/10/2023
| Implemented |