| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | Individual #1 was admitted into the program on 5/8/25. Documentation notes that a Mantoux test was completed on 2/24/24 greater than one year prior to admission as required. | 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. | Upon notification of the Mantoux being out of compliance, the nursing staff was re-trained on ODP Announcement 24-094 which states that "Initial physical examinations for individuals and staff must include a TB test." The re-training included the fact that the time-frame for an "initial exam" is within one year of the individual's admission and is inclusive of all applicable testing, meaning that an initial TB test must be completed within that one year of a new admission. Although TB testing results remain relevant for two years, a new admission must have the testing done within one year prior to admission. |
11/21/2025
| Implemented |
| 6400.144 | Individual #1 received treatment at Urgent Care for "swollen feet" on 5/27/25. Report of the visit noted instructions in the "prescribed treatment" section of the form completed by the treating physician. The section noted "Compression stockings, remove for sleep. Back to bed after all meals, 1 hour, (at least three times daily), elevate feet above heart level, float heels while in bed. Use of compression stockings was confirmed. There was no evidence that positioning after meals and floating heels while in bed was completed as prescribed. | 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.
| Protocol for individual's prescribed treatment after visit to an urgent care facility was in place at time of inspection. Document will be sent. Staff were trained on said protocol but there was no tracking form in place to show that staff had been following physician's orders. A daily tracking form was put into place and all staff who work at the individual's home were trained on the tracking system by the individual's Program Specialist. |
11/05/2025
| Implemented |
| 6400.52(c)(2) | There was no documentation that Staff #2 had training on The prevention, detection and reporting of abuse, suspected abuse and alleged abuse as required. | 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. | Staff #2 did, in fact, have documentation on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse as required, however this documentation was sent to the inspectors after the exit interview. This documentation will be provided again as well as documentation that staff #2's ongoing annual training syllabus includes training on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in subsequent years. |
11/04/2025
| Implemented |
| 6400.52(c)(4) | There was no documentation to support that Staff #2 had annual training on recognizing and reporting incidents as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | It was confirmed that Staff #2's training hours did not include annual training on Recognizing and Reporting Incidents. Staff #2's training hours coordinator was contacted and her training syllabus was adjusted to ensure that she receives training on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse annually going forward. |
11/04/2025
| Implemented |