| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The annual assessment dated 7/25/24 notes that Individual #1 is unable to identify coins or bills, cannot count money and is able to safely carry $1.00. Agency staff assist Individual #1 with all purchases.
Several requests for up to date financial records were made with 10/23 and 1/24 being presented as all that were available for the annual review period. Financial documents for 6/24, 7/24, 8/24 and 9/24 were found at the home. The agency could not providence documentation that an up to date financial record of the dates and amounts of deposits and withdrawals for the individual to cover the months of 11/23, 12/23, 2/24, 3/24, 4/24 and 5/24. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Beginning 10/1/24, financial books will be in the home to track receipts/deposits for every individual¿s funds. |
10/01/2024
| Implemented |
| 6400.112(a) | There was no documentation to illustrate that fire drills had been completed in March 2024 and May 2024 as required.
(REPEAT VIOLATION 9/4/23) | An unannounced fire drill shall be held at least once a month. | There is no way to correct this oversight, however two extra drills will be run (one in October and one in November) to make up for that practice that was missed. |
10/04/2024
| Implemented |
| 6400.141(c)(9) | Individual #1 reached the age of 40 on 5/31/23. Individual #1 had an annual physical completed on 10/3/23. The physical noted that "PSA ordered." There was no documentation to support that the PSA had been completed as directed.
(REPEAT VIOLATION 9/15/23) | The physical examination shall include: A prostate examination for men 40 years of age or older. | On 10/2/24, the missing exam was scheduled for individual #1.
The prostate examine was completed on 10/3/24 for individual #1. |
10/03/2024
| Implemented |
| 6400.142(a) | Documentation of a dental exam completed on 8/2/23 was provided for Individual #1. There was no additional documentation to indicate that an annual appointment was completed in 2024. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | A dental appointment was scheduled for 10/8/24 |
10/03/2024
| Implemented |
| 6400.142(e) | Documentation indicates that Individual #1 had a dental appointment on 8/2/23. Documentation of the appointment noted that a six month return visit was needed. There was no documentation provided to indicate that the recommended follow up appointment was completed as required. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | On 10/3/24 a dental appointment was scheduled for this individual.
On 10/8/24 this individual went to the dentist. |
10/08/2024
| Implemented |
| 6400.144 | Individual #1 had a Gastroenterologist appointment on 1/11/24. The completed visit form noted that a "6 month" follow up was required. There was no documentation to indicate that the follow up appointment was completed as recommended.
Individual #1 reached the age of 40 on 5/31/23. Individual #1 an annual physical completed on 10/3/23. The physical noted that "PSA ordered." There was no documentation to support that the PSA had been completed as directed.
Individual #1 last had a dental exam on 8/2/23. A six month follow up was recommended. There was no documentation to support that the required annual or recommended six-month appointments had been completed.
As stated in the Individual Support Plan (ISP) for Individual #1 last updated on 9/3/24 Individual #1 is "non-ambulatory and independently utilizes a motorized wheelchair. [Individual #1]'s gross motor skills and fine motor skills are limited." Individual #1's assessment dated 7/25/24 notes that they are physically "unable" to trim their toenails.
Agency case notes provided began at 11/7/22 indicating that attempts had been made to schedule nailcare with a podiatrist. Individual #1 then required medical treatment at Tower Health Urgent Care on 7/11/23 due to "overgrown toenail, irregular toenail."
An agency case note indicated that there was an appointment secured for 7/31/23. There was no documentation that this appointment occurred.
Individual #1 was then seen at Berks Community Health and Dental Center 9/21/23. Reason for appointment "Long, cracked nails." Physician notations included: "Nike shoes are too big (7) & too narrow (M Nike) normal width pressure to bunion needs md for size 1 extra wide & try lycra to prevent pressure wounds. Need to clean out toe webs weekly" "Mild pad and pressure bunions L & R." Noted procedures conducted were "Trim all nails. Clean out web debris" with recommendations to "Return 3-4 months." There was no documentation to support that the recommendation on shoe size and type were explored. The shoes in the closet of Individual #1 at the time of inspection were mostly Nike in sizes Y7 and 8.5M. There were no shoes in the closet that appeared to be made of the Lycra noted to try and none labeled to be wide as recommended.
Documentation indicates that a podiatry appointment was conducted on 12/7/23 with physician noting procedure as "debride mycotic elongated nails" and recommendation to "need to keep the webs dry for pressure areas daily" and "return 3/14/24."
As of 9/19/24 there was no documentation to indicate that further appointments had been conducted as recommended and no evidence that recommendations had been followed.
(REPEAT VIOLATION 9/13/23) | 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.
| Gastro was scheduled immediately for first available on 10/25/24
Prostrate Exam was scheduled immediately and done 10/3/24
Dental exam scheduled immediately and completed 10/8/24
Podiatry scheduled immediately for 10/24/24 |
10/25/2024
| Implemented |
| 6400.181(a) | The assessment for Individual #1 dated 7/25/24 did not address progress or growth for any of the areas as required under 6400.181(13): Health, Motor and Communication skills, activities of residential living, personal adjustment, socialization, recreation, Financial Independent, Managing Person property, and Community Integration. The assessment included current levels of functioning which did not change from the assessment completed in 2023. The annual assessment was not complete. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | On 10/7/24 the progress statements were added for each section of the annual assessment. |
10/07/2024
| Implemented |
| 6400.18(i) | Incident #9192226 was entered on 3/31/23 with the last extension due on 11/15/23. Incident #9270381 was entered on 8/25/23 with the last extension due on 4/17/24. Extensions for named incidents have lapsed and reports have not been finalized as required. At time of inspection on 9/18/24 the provider had not finalized either incident within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension as required.
(REPEAT VIOLATION 9/14/23) | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Incident 9192226 was closed on 9/26/24 in HCSIS
Incident 9270381 was closed on 9/18/24 in HCSIS |
09/26/2024
| Implemented |
| 6400.181(f) | The agency provided an annual Individual Support Plan (ISP) meeting date of 7/26/24. The assessment completed by the agency was dated 7/25/24, one day prior to the annual individual ISP meeting. The assessment completed on 7/25/24 was not completed in time to share with the plan team members at least 30 calendar days prior to the individual plan meeting as required. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | This citation is not able to be corrected. |
10/04/2024
| Implemented |