| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | An unannounced fire drill was not completed July & August 2024. | An unannounced fire drill shall be held at least once a month. | -Provider retrieved fire drills from the service location in question.
- Provider reviewed fire drill procedures with all staff during the bi-weekly conference call to ensure understanding of their roles and responsibilities.
|
10/25/2024
| Not Implemented |
| 6400.112(d) | The fire drill completed on 6/30/24 exceeded 2.5 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | -Provider retrieved fire drills from the service location in question.
- Provider reviewed fire drill procedures with all staff during the bi-weekly conference call to ensure understanding of their roles and responsibilities.
|
10/25/2024
| Not Implemented |
| 6400.141(c)(13) | For individual 1, the sections for allergies and contraindicated medications was left blank on the most recent physical. | The physical examination shall include: Allergies or contraindicated medications. | Individual 1's physical form was returned to their primary care physician to have the allergies and contraindicated medication completed. Both sections were updated and returned to provider nursing agency. |
10/25/2024
| Not Implemented |
| 6400.142(a) | Individual 1 had no records of dental examinations on file. | 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. | Individual 1 attended their scheduled dental appointment on October 1, 2024. Dental visit form will be filed in his medical binder. |
10/25/2024
| Not Implemented |
| 6400.151(a) | Staff Member 4's physical exam was not completed prior to date of hire. | 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. | Provider developed a new hire document that will be used for all newly hired staff members. |
10/25/2024
| Not Implemented |
| 6400.151(c)(3) | Staff Member 2's 12/06/2022 physical does not contain communicable disease clearance. [REPEAT VIOLATION] | 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 member 2 submitted documentation from their physical in October of 2023 that stated they were free from communicable diseases. Document will be attached to staff member 2s physical form and files in their employee file. |
10/25/2024
| Not Implemented |
| 6400.151(c)(4) | Staff Member 2's 12/06/2022 physical does not assess medical problems that might interfere with the health of individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Staff member 2 submitted documentation from their physical in October of 2023 that stated they were free from communicable diseases. Document will be attached to staff member 2s physical form and files in their employee file |
10/25/2024
| Not Implemented |
| 6400.24 | The 1970 Controlled Substances Act requires accurate counts be kept for controlled medications. There were a number of days where staff did not document Individual 1's Clonazepam medication count for the 8am shift on: 9/9, 9/11, 9/13, 9/14, 9/16, 9/20, and 9/24. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | -Provider retrained individual staff members on how to correctly count the controlled medication.
- A medication count was conducted by an On-call supervisor and Executive Director to make sure medication count and number of pills in the blister package was correct. |
10/25/2024
| Not Implemented |
| 6400.32(d) | The agency has completed an excessive amount of overnight fire drills at this property causing frequent interruptions to the Individual's sleep. Overnight drills were completed on 11/15/23; 11/30/23; 12/31/23 and 4/12/24. | An individual shall be treated with dignity and respect. | Provider developed a monthly fire drill schedule that includes dates, times, and specific objectives for each drill to prevent an excessive amount of fire drills to be completed on 1 shift. |
10/25/2024
| Not Implemented |
| 6400.52(c)(1) | Staff Members 1, 2, and 3 have not received training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships in the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The provider will implement an annual training plan for each staff member which covers all required training. The annual training planned will have a list of the required training, the date training was completed, and next due date of training for each staff member. All training records will be filed in each employee¿s file for record keeping purposes. |
10/25/2024
| Not Implemented |
| 6400.52(c)(2) | Staff Members 1, 2, and 3 have not received training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The provider implemented an annual training plan for each staff member which covers all required training. The annual training planned will have a list of the required training, the date training was completed, and next due date of training for each staff member. All training records will be filed in each employee¿s file for record keeping purposes. |
10/25/2024
| Not Implemented |
| 6400.52(c)(3) | Staff Members 1, 2, and 3 have not received training in individual rights in the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The provider implemented an annual training plan for each staff member which covers all required training. The annual training planned will have a list of the required training, the date training was completed, and next due date of training for each staff member. All training records will be filed in each employee¿s file for record keeping purposes. |
10/25/2024
| Not Implemented |
| 6400.52(c)(4) | Staff Members 1, 2, and 3 have not received training in recognizing and reporting incident the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The provider implemented an annual training plan for each staff member which covers all required training. The annual training planned will have a list of the required training, the date training was completed, and next due date of training for each staff member. All training records will be filed in each employee¿s file for record keeping purposes. |
10/25/2024
| Not Implemented |
| 6400.52(c)(5) | Staff Member 1 has not received training in the safe and appropriate use of behavior supports in the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | The provider implemented an annual training plan for each staff member which covers all required training. The annual training planned will have a list of the required training, the date training was completed, and next due date of training for each staff member. All training records will be filed in each employee¿s file for record keeping purposes. |
10/25/2024
| Not Implemented |
| 6400.52(c)(6) | Staff Member 1 has not received training in the implementation of individual plans in the 2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Provider will implement an annual training plan for each staff member which covers all required training. The annual training planned will have a list of the required trainings, date training was completed, and next due date of training for each staff member. All training records will be file in each employees file for record keeping purposes. |
10/25/2024
| Not Implemented |
| 6400.165(g) | Psychotropic medication reviews for Individual 1 were not completed every 3 months. Appointments on record were dated 07/31/2024, 02/05/2024, 09/13/2023. | 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. | Provider's executive Director discussed the regulation for the 90 day dates with the nursing practitioner who oversees individual 1's psychotropic medication. |
10/25/2024
| Not Implemented |