| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff 6 - no criminal history record check was found in the personnel record. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| This violation is not entirely accurate: staff person had the child abuse fingerprinting and PA state police background checks in their personnel files. Staff completed FBI criminal history fingerprinting on 2/28/23 |
03/31/2023
| Not Accepted |
| 6400.43(b)(1) | Per the site manager, Embolden's COVID policy states that an individual is supposed to quarantine following a positive COVID-19 test result. Individual 3 was not quarantining, as this individual was observed in common areas of the home. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Individual three was quarantining in the privacy and comfort of their own home. Embolden follows CDC guidelines for the 5-day home quarantine period, but does not and cannot force any individual to self quarantine in their bedrooms. All the individuals in the home were quarantined for 5-days and tested-- each tested negative-- and their respective teams were informed of the positive COVID outbreak prior to the quarantine period. Embolden did not allow visitations during the quarantine period. |
03/31/2023
| Not Accepted |
| 6400.64(a) | The oven and stove top had a large amount of grease build-up that needs to be cleaned. | Clean and sanitary conditions shall be maintained in the home. | Oven and stove top have been cleaned. |
03/31/2023
| Not Accepted |
| 6400.67(a) | The miniblinds in Individual 2's ensuite bathroom were missing seven slats. | Floors, walls, ceilings and other surfaces shall be in good repair. | Blinds were replaced. |
03/31/2023
| Not Accepted |
| 6400.144 | Pharmaceutical services are not being fully rendered for Individual 2. Their Lokelma medication indicates it is to be administered every other day; its administration has been signed for every day in February on the MAR. The medication is also stored without its pharmacy label. As such, it cannot be determined that the medication is being administered according to prescribed orders. The individual's PRN albuterol inhaler was not stored with their other medications and also did not have a pharmacy label; it was in the individual's bedroom. Their ISP does not indicate that they self-medicate. The individual's blood sugar readings are not logged consistently, and when logged in daily notes, are sometimes logged incorrectly, such as on 2/3/23 when the meter read 185 but was recorded in a daily note as 182, and on 2/4/23 when the meter read 142 but was recorded as 140. | 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.
| Prescriber was contacted to provide clear instructions concerning the administration of Lokelma -- essentially to specify the days it should be administered-- as the current instruction "every other day" is unclear and is open to misinterpretation. Pharmacy has yet to receive the new orders for re-labeling. The PRN Abuterol inhaler is stored in its original container and kept with the other medications. Staff persons have been re-instructed on reading the blood sugar meter accurately. |
03/31/2023
| Not Accepted |
| 6400.151(a) | Staff 12 - the last physical found in the record is for 9/13/2020. The next physical was due in September of 2022 and was not found in the record. | 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. | Physical was included in the staff record sent via email on March 7, 2023. |
03/31/2023
| Not Accepted |
| 6400.151(c)(2) | Staff 12 - the last TB test was completed on 9/13/2020 and the record does not include a test being performed in September of 2022. | 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. | TB was included in the staff record sent via email on March 7, 2023. |
03/31/2023
| Not Accepted |
| 6400.151(c)(3) | Staff 12 - there was no statement indicating that the staff member is free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff person signed the ECA Health Attestation form verifying that they are free of communicable diseases, information was sent via email on March 7 2023 |
03/31/2023
| Not Accepted |
| 6400.32(d) | Individual 3 tested positive for COVID-19 on February 14, 2023, and was not quarantining in a separate section of the home that he shares with his two roommates: Individual 2 and Individual 4. During the physical site inspection, Individual 3 was observed in the shared living room area and staff reported that he also ate breakfast this morning in this shared space. Individual 3 also shares a bathroom with Individual 4. The house manager states that neither Individual 2 or Individual 4 have been tested for COVID-19 since Individual 3's positive test. | An individual shall be treated with dignity and respect. | Individual three was quarantining in the privacy and comfort of their own home. Embolden follows CDC guidelines for the 5-day home quarantine period, but does not and cannot force any individual to self quarantine in their bedrooms. All the individuals in the home were quarantined for 5-days and tested-- each tested negative-- and their respective teams were informed of the positive COVID outbreak prior to the quarantine period. Embolden did not allow visitations during the quarantine period. |
03/31/2023
| Not Accepted |
| 6400.166(a)(13) | Individual 4's Celecoxib medication is to be administered every morning and evening for mild pain per their MAR. Staff has only signed for the morning administrations throughout the month of February; all evening administrations were not signed for in the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Individual 4's medications are packaged together in one singular blister pack with AM medications in one column and the PM medications in a separate Colum. Medication was administered, staff persons failed to initial the PM medications, but medication counts reflect that they were administered. Going forward supervisory personnel shall check MARs at least weekly to ensure that staff initial every administration of each medication. |
03/31/2023
| Not Accepted |
| 6400.169(d) | Staff 12 - there was no documentation found for the 12/2022 MAR review as required. The handwashing checklist was not completed in 2022. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | As requested, MAR review records concerning staff person 23 was sent via email March 7 2023. Ensure that all active personnel records are kept separately from inactive personnel records. |
03/31/2023
| Not Accepted |