| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The First Aid kit is missing a thermometer. | 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. | -Provide Placed Thermometer in the First Aid Kit on 9/1/24 |
09/01/2024
| Implemented |
| 6400.24 | Individual 1 is being charged in excess of 72% of the SSI maximum rate plus the Pennsylvania State Supplementary Payment (SSP) at a rate of $722.88 per month in room and board charges per agreement signed 3/25/2024. The maximum charge the individual should be incurring is $694.87 with respect to the SSI maximum of $943 and SSP rate of $22.10 currently. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances.
§ 6100.686. Room and board rate.
(a) If the actual provider room and board cost as specified in § 6100.684 (relating to actual provider room and board cost), less any benefits as specified in § 6100.685 (relating to benefits), is more than 72% of the SSI maximum rate plus the Pennsylvania supplement, the following criteria shall be used to establish the room and board rate:
(1) An individual's share of room and board may not exceed 72% of the SSI maximum rate plus the Pennsylvania supplement. | -Provider updated Room and Board Contracts for All individuals to reflect correct Room and Board amount for Max SSI/ SSP
-Provider staff had a team meeting addressing Room and Board Contracts on 9/3/24
-Provider was retrained on Room and Board Contract Regulation on 9/3/24
-Quality Angels has updated all individuals' Room and Board Residency Agreements to the DP 1077. |
08/30/2024
| Implemented |
| 6400.165(b) | Individual 1 - Triamcinolon Acetonide 0.1% - 8am/8pm is available in the med box, but not on MAR or discontinued on the mar (staff stated that medication was discontinued). Eliquis 5 mg -- 8a/8p available in the med box and is not on mar. Estradiol 0.1% - is available in med box but not showing on the MAR. Nystatin 1 teaspoon by mouth 4 times a day. 8a/12n/4p/8p -- is missing from med box, and is not showing discontinued. Medication is still on mar. Melomoxican 7.5 MG is available in the med box and is missing from MAR. Oxycodone -- 5 MG is available in the med box but is not on mar / No narcotic count sheet available. | A prescription order shall be kept current. | Provider
- Immediately update the MAR to reflect all medications currently in the med box.
- Conduct a full review of all medication orders, prescriptions, and MARs to ensure accuracy.
- Ensure all narcotic medications, like Oxycodone, are documented with a narcotic count sheet, and provide staff training on the proper handling of controlled substances.
-Provider contacted Community Care Pharmacy to replace the Medication, Update MAR's
-Medication's were replaced/ Medications were discontinued by Physician, new Medication List was updated, all medication was resolved/ replaced inside individuals Medication Box
-Provider issued Corrective Action/ Informal Counseling to Staff regarding Medication Management
-Provider Retrained Staff on Medication Administration on 9/12/24
-Provider Entered EIM for Medication Error |
09/01/2024
| Implemented |