| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees 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. Staff #4 of hire was 9/29/21 and her criminal record check was not completed until 4/22/22 which exceeds the time frame required. | 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.
| The Agency has developed a policy in place to ensure that all company new employees will not start work until after a favorable background check is completed. |
08/25/2022
| Implemented |
| 6400.81(k)(5) | Individual #2's bedroom does not have a closet or wardrobe space with clothing racks and shelves. Individual #2 has full access to the spare bedroom connected to their bedroom. Individual #2 uses this space as extra storage for personal belongings. The spare bedroom used for storage by Individual #2 also lacks a closet or wardrobe space with clothing racks and shelves. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | A closet with clothing rack and shelves has been built on 8/10/2022 in the individual¿s room. |
08/25/2022
| Implemented |
| 6400.112(c) | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill conducted on 7/24/22 did not reflect which exit was used to exit the home. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The fire drill form completed on 7/24/2022 was reviewed and corrected. |
08/25/2022
| Implemented |
| 6400.141(c)(1) | Individual #2 had his annual physical completed on 4/12/22. This physical did not include individuals' medical history. | The physical examination shall include: A review of previous medical history. | The individual physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The individual¿s medical history was added as well during completion. |
08/25/2022
| Implemented |
| 6400.141(c)(2) | Individual #2 had his annual physical completed on 4/12/22. This physical did not contain information to support that a general physical exam had been completed. | The physical examination shall include: A general physical examination. | The individual¿s initial physical was completed on 4/12/2022 but on a non ODP approved form. A new form has been completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals on 8/8/2022 with all information. |
08/25/2022
| Implemented |
| 6400.141(c)(3) | The physical presented for Individual #2 was completed on 4/12/22. Documentation on the physical did not contain a verification that immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control had been completed. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The individual physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals on 8/8/2022. The individual¿s immunizations were verified and entered on the physical form. |
08/25/2022
| Implemented |
| 6400.141(c)(6) | Individual #2 had his annual physical completed on 4/12/22. This physical did not include individuals TB test. There was no documentation provided for this individual that reflects a TB was completed. | 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 individual physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals on 8/8/2022. The individual¿s TB screening has been scheduled to be completed on 8/29/2022. A copy of the result will be emailed to you as soon as received. |
08/25/2022
| Implemented |
| 6400.141(c)(11) | The physical presented for Individual #2 was completed on 4/12/22. Documentation on the physical did not contain an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 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 individual physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The individual¿s completed physical contained assessment documentation on the individual¿s health maintenance needs, medication regimen and the need for blood work. |
08/25/2022
| Implemented |
| 6400.141(c)(12) | The physical presented for Individual #2 was completed on 4/12/22. Documentation on the physical did not contain a review of the physical limitations of the Individual. | The physical examination shall include: Physical limitations of the individual. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained a review of the physical limitations of the individual. |
08/25/2022
| Implemented |
| 6400.141(c)(13) | The physical presented for Individual #2 was completed on 4/12/22. Documentation on the physical did not contain information pertaining to allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals on 8/8/2022. The new form completed contained information pertaining the individual¿s allergies or contraindicated medications. |
08/25/2022
| Implemented |
| 6400.141(c)(14) | The physical presented for Individual #2 was completed on 4/12/22. Documentation on the physical did not contain medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained medical information pertinent to the individual¿s diagnosis and his treatment as well during emergency situations. |
08/25/2022
| Implemented |
| 6400.141(c)(15) | Individual #2 has his annual physical completed on 4/12/22. This physical did not have any instruction pertaining to the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained special instructions for the individual¿s diet. |
08/25/2022
| Implemented |
| 6400.144 | Individual #2 had his initial physical exam on 4/12/22. At this exam there was a follow up appointment scheduled for 7/12/22. There was no documentation provided at the time of inspection that the individual attended this appointment. | 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.
| This appointment was completed on 7/12/22 and the documentation for that appointment was part of the documentation that we scanned and submitted for licensing review last month. |
08/25/2022
| Implemented |
| 6400.181(a) | Individual #2 was admitted into the program on 4/6/22 and had an initial assessment completed on 5/18/22. The assessment completed was primarily a checklist. The required sections of Lifetime Medical History, Strengths, Dislikes, Supervision needs, Health, Recreation, Managing Personal Property and Community Integration were either missing or lacked adequate information. The assessment lacked personalization and was not individualized. The assessment cannot be vague or nonspecific. Assessments cannot be completed simply to meet the regulatory or programmatic requirements. Providers must develop assessments that are meaningful, accurate, and useful. | 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. | Another annual assessment was completed on 8/3/2022 by the agency Program Specialist. The required sections of the individual¿s Lifetime Medical History, Strengths, Dislikes, Supervision needs, Health, Recreation, Managing Personal Property and Community Integration were personalized based on the individual¿s goals and outcomes. |
08/25/2022
| Implemented |
| 6400.34(a) | Incomplete review of individual rights for Individual #2 was completed on 4/6/22. The following rights were not reviewed: 34D, E, F, G, I, P, Q, R, S, T, U and V. Full review is required to satisfy the regulation. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | A staff training on all individual rights statement has been completed on 8/15/2022. The individual was trained as well on his rights. |
08/25/2022
| Implemented |
| 6400.46(b) | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection. There was no documentation that reflected staff #3 had fire safety training. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | This training was completed on 6/23/2021 and was part of the documentation that was submitted for licensing last month. |
08/25/2022
| Implemented |
| 6400.165(e) | · Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. Individual #2 had several medications listed on the Medication Administration Record (MAR) as being discontinued however there was no documentation to determine when the medication was discontinued. These medications included Lantus, which was last signed for on 7/11/22. Trazadone appears that it was signed for at the beginning of the month, however large writing of the word DISCONTINUED covered what appeared to be initials and it is unclear when this medication was stopped. Remeron was a medication listed on a medical form as being discontinued on 7/21/22, however the MAR was signed out until 7/25/22 and d/c occurred after that date. It is unclear when this medication was discontinued and who discontinued it. Catapres/Clonidine was a medication on a medical form as being discontinued on 7/21/22, however the MAR was signed out until 7/25/22 and it is unclear when this medication was to be discontinued and when it was no longer being administered to the individual. Divalproex was administered twice a day at 8am and 8pm and appeared to be initialed in the beginning of the month, however the word discontinued was written largely across the initial area and it is unclear when the medication was discontinued or last administered. Hydroxyz, appeared to be initialed in the beginning of the month, however the word discontinued was written largely across the initial area and it is unclear when the medication was discontinued or last administered. Chlorpromaz had no entries for the entire month of July, and a large D/C written in where the prescription information is listed on the MAR. There was no clear date to know when this medication was discontinued. Ibuprofen was a medication to be administered as needed listed on the MAR to be taken for pain, however there was an unidentified form that states it was discontinued. Unsure who recommended this medication to be discontinued or when this medication was discontinued and if so. The MAR also did not reflect that the medication was to be discontinued. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | All individual¿s old medication has been returned to the Pharmacy immediately after licensing was completed. Individual¿s Doctors were contacted for new scripts with all medications in question. The Pharmacy was also contacted for new med label with only current medications. All new MARs have been corrected with only current medications. All agency staff has been re-trained on PA medication administration training on 8/04/2022. |
08/25/2022
| Implemented |
| 6400.166(a)(5) | The July 2022 Medication Administration Record (MAR) for Individual #2 indicated that the strength of the medication Sertraline was "50mg." The strength of the Sertraline on the blister pack in use for Individual #2 was "100mg." The strength on the July 2022 MAR was incorrect.
The July 2022 Medication Administration Record for Individual #2 indicated that the strength of the medication Clozaril was "120mg." The strength of the Clozaril on the blister pack in use was "100mg." The strength on the July 2022 MAR was incorrect. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Individual¿s prescribing Doctor for his Setraline medication was immediately contacted for new scripts with the correct strength of the medication. The Pharmacy was also contacted for new med medication and med label. The new MAR is been corrected with the new strength. All agency staff has been re-trained on PA medication administration training on 8/04/2022. |
08/25/2022
| Implemented |
| 6400.166(a)(11) | Individual #2 is prescribed Metaformin/Glucophage 100mg tab to be taken twice a day. The Medication Administration Record (MAR) does not reflect the diagnosis or reason for this medication to be administered. Individual #2 is also prescribed Trulicity to be injected under the skin every 7 days. The MAR does not have a diagnosis or reason for this medication to be administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Individual¿s prescribing Doctor for his Metformin medication was immediately contacted for new scripts with the correct diagnosis or reason for the medication. The Pharmacy was also contacted for new med medication and med label . September MAR has the diagnosis of the medication for diabetes. All agency staff has been re-trained on PA medication administration training on 8/04/2022. |
08/25/2022
| Implemented |
| 6400.166(c) | Individual #2 is to have accuchecks before meals at 7:30am, 11:30am, 4:30pm and 9pm. The Medication Administration Record (MAR) reflects that he refused these checks on 7/11/22 through 7/25/22 at the times of 11:30am and 4:30pm. The MAR also reflects that individual refused the 9pm checks on 7/21/22 though 7/25/22. These refusals shall be reported to the prescriber. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | Individual¿s prescribing Doctor for his accuchecks has discontinued it. The Pharmacy was also contacted for it to be removed from his MAR. All agency staff has been re-trained on PA medication administration training on 8/04/2022. |
08/25/2022
| Implemented |
| 6400.166(d) | Individual #2 had his initial appointment with a psychiatrist on 7/11/22. The documentation provided from this visit reflects that a new medication was prescribed. The medication Zoloft 100mg ½ to be administered two times daily. The July Medication Administration Record did not reflect this medication and there is documentation to show the medication was discontinued. | The directions of the prescriber shall be followed. | The medication was immediately entered on the MAR. Individual¿s Psychiatrist was contacted immediately after licensing for a script to be sent to the Pharmacy. The Pharmacy was also contacted for a new medication label and the medication to be entered on the MAR, which was done. All agency staff has been re-trained on PA medication administration training on 8/04/2022.. |
08/25/2022
| Implemented |