| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-Assessments are to be completed three to six months prior to the certificate expiring or six to nine months after the last annual inspection. This would place the self-assessments as being due from 4/18/24 through 8/30/24. The self-assessment was not completed until 9/4/24 to 9/27/24. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The violation occurred due to a misunderstanding of the inspection notification letter.
To avoid future violations, by October 31st, 2024, the Director of Programs will add the due date for the self-assessments to the calendar shared by the Director of Operations, the CEO, and the CAO. The CEO will ensure the information is entered on the calendar by 10/24/2024.
This action will ensure a four-point checking system: The Director of Programs and the Director of Operations will complete the self-assessment, and the CEO will review it to ensure regulatory compliance. |
10/24/2024
| Implemented |
| 6400.22(c) | Individual #1's funds were spent on health and beauty products that are to be included with room and board on 2/28/24 and 4/20/24. | Individual funds and property shall be used for the individual's benefit. | The participants used their own personal funds to purchase health and beauty products.
The violation occurred because staff may not have been fully aware of the rules that pertain to allowable purchases with personal funds as it relates to the regulatory obligation of the agency to provide personal care items for the participant.
All staff will receive updated training on the correct use of individuals personal funds, outlining what is appropriate for purchase and what is not. The Program Director will provide the mentioned training by Oct. 31, 2024. Guidelines will be set so that staff and participants are clear on what the obligation is of the agency to provide health and beauty products. Monthly audits will be performed to ensure compliance is maintained, According to 55 PA Code Chapter 6400.22(c). An EIM was entered October 9th. The funds that are in discrepancy will be reimbursed by AIMED at the conclusion of the CI. |
10/31/2024
| Implemented |
| 6400.22(d)(1) | Individual #1's financial record is not current and up to date. Beginning in March 2024 there were mathematical errors that were never rectified. Additionally, there were two receipts that were not logged on the sheet. One was on 3/12/24 for $19.26 at Dollar General. The other was for $16.58 spent on 8/8/24. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The participants' financial records were inaccurate since March 2024 and never properly audited and reconciled. We failed in keeping accurate documentation required by ODP regulations. Mathematical errors were identified but not corrected, proving to be a lack of oversight from the Residential Supervisor and Program Specialist who are to ensure accuracy and compliance. The two receipts that were missing and not properly logged, identified a weakness in the organization of financial tracking.
The PS will update all financial records to the current date ensuring that the participant ledgers balances are accurately reflected. This task will be completed by 10/31/24. Reimbursements will be made as needed. |
10/31/2024
| Implemented |
| 6400.22(e)(3) | The following receipts were missing from Individual #1's record: 2/4/24-$20 given to Individual #1, 3/9/24-$21.13 spent at Wal-Mart, 3-18-24-$23.49 spent at Rutters or Dollar General, 6/23/24-$32 spent at Papa's John, 6/25/24-$28 spent at Hair Cuttery, and 7/31/24-$60 given to Individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Several purchases made with the participant were not properly documented with receipts as 6400.regulations require. Any purchase over $15.00 made by or for the participant must have a receipt or a record of the expense. This procedure did not happen, which put the site in non-compliance status with regulation 6400.22 (e)(3). Due to the staff not following proper procedures for collecting receipts caused this violation.
Immediate staff training on the importance of collecting and submitting receipts for all purchases over $15.00, by the Regional Program Director on 10/17/2024.
The Program Director will create a receipt submission policy that explains procedures to follow in the event of a lost receipt.
Residential Supervisor will conduct a daily D at the change of shift to ensure that going into the new day that all ledgers are accurat |
10/17/2024
| Implemented |
| 6400.82(f) | At the time of the inspection, there were no paper towels or individual hand towels available at the sink used for the bathroom in the basement. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | At the time of inspection, there were no paper towels at the sink in the basement. This happened because that toilet is not a toilet that is regularly used and the sink is a mop sink that is not regularly monitored for said supplies
Staff immediately stocked the sink with towels. We will also place a reminder to check the sink area for supplies daily to ensure that this violation does not re-occur. |
10/16/2024
| Implemented |
| 6400.111(f) | The fire extinguishers were inspected on 4/6/23 and not again until 4/10/24, outside of the annual timeframe. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher service was scheduled by the company that completed the inspections. The due date was unknown by the staff responsible for operations
The fire extinguisher service was scheduled by the company that completed the inspections. The due date was not placed on the calendar by VP of Operations. |
10/16/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's most recent physical completed on 7/10/24 does not document their health maintenance needs, medication regiment, or bloodwork. These factors are not documented on the physical at all. | 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 provider used a new physical form recommended by the Western Regions AE this licensing year, unfortunately, it did not have the regulated criteria on the new form which led to violations.
The CEO plans to reinstate AIMEDs physical form that has been used in the past, which included the assessment of the individual's health maintenance need, medication regimen and the need for bloodwork at recommended intervals. |
11/01/2024
| Implemented |
| 6400.141(c)(12) | Individual #1's most recent physical completed on 7/10/24 does not document their physical limitations. This section is not on the physical form. | The physical examination shall include: Physical limitations of the individual. | The provider used a new physical form recommended by the Western Regions AE this licensing year, unfortunately, it did not have the regulated criteria on the new form which led to violations.
The CEO plans to reinstate the physical form that has been used in the past, which included physical limitations of the individual. |
11/01/2024
| Implemented |
| 6400.145(2) | Individual #1's emergency medical plan does not document their method of transportation. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | The omission of this information was due to an oversight during the creation and review of the plan. The plan unfortunately did not go through a thorough quality assurance process to ensure all regulatory elements were included.
The plan for the participant will be immediately reviewed and updated to reflect the mode of transportation during an emergency situation. Staff will be retrained on the emergency plan for the participants by 10/31/24 by the Regional Program Director. |
10/31/2024
| Implemented |
| 6400.181(a) | The most recent assessment written on 8/7/24 cannot be accepted as a complete assessment. The following information was either missing or not thoroughly addressed: Preferences, Needs, Dislikes, Communication, Personal Adjustment, Personal Needs with or without Assistance, Ability to Evacuate in a Fire, Disability/Functional/Medical Limitations, Psychological, Recommendations, and Progress in any of the Categories. | 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. | The recent assessment for the participant was found to be incomplete. Key areas that need to be addressed were either missing or very limited in detail. This violation occurred because the agency was trying to put together a very in depth and strong assessment to address all necessary information but failed to build the content out far enough.
The CEO or designee is in the process of rebuilding the new template through THERAP that encompasses all the regulatory points outlined in regulation 6400.181(a). The target date for completion is November 1,2024. |
11/01/2024
| Implemented |
| 6400.211(b)(1) | Individual #1's demographic information does not document the name/address/phone of the emergency contact. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Incomplete documentation of the participants record. There was an oversight during the entering of the data into the record. There was no regular audit of the documentation which led to the missing information.
Quarterly audits will be done by the Regional Program Director to review the charts to ensure all necessary data is put in the record. |
10/16/2024
| Implemented |
| 6400.211(b)(3) | Individual #1's demographic information does not document the name/address/phone of who to contact for medical consent. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| The incorrect form was placed in the participants chart.
The Regional Program director will update with the correct form and information in the individuals chart by 10/31/2024 |
10/31/2024
| Implemented |
| 6400.165(g) | (Repeat Violation from 10/18/23) The quarterly psych med review appointment held on 5/31/24, 7/12/24 did not document whether Individual #1 is to continue all psych meds as previously prescribed. Individual #1's psych med appointment on 2/15/24, 5/3/24 did not document the reason for prescribing each of the psych meds. | 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. | The doctor's notes did not clearly state if the participant should continue all prescribed psychiatric medications, the physician also did not list the reason as to why the medications were prescribed. The attending staff person with the participant did not ensure that all pertinent information was documented per regulation.
The Regional Program Director will conduct a training with all staff on Oct. 17, 2024, so that the staff understands the required documentation from the physician for a quarterly psychiatric medication review.
The staff will use the medication review checklist during appointments to ensure all criteria pertaining to regulation 6400.165 (g) is met. Within 24 hours of the appointment staff will submit the documentation to the Program Director or review. |
10/17/2024
| Implemented |
| 6400.195(a) | Individual #1 has restrictive procedures identified in the Behavior Support Plan developed on 8/23/24 that are "allowed to be used." These restrictive procedures were not approved by HRT. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The Senior Admissions & Clinical Officer was unaware that using a one-person or two-person guide is an approved restrictive procedure, which requires a Restrictive Procedure Plan to address the need for the holds.
By December 31, 2024, the Senior Admissions & Clinical Officer shall develop an RPP for the one-person or two-person guide and present the plan to the Human Rights Committee for review and approval. When approved, the staff that work with the Individual shall be trained by The Senior Admissions & Clinical Officer, or designee, to ensure their comprehension of the holds and how and when to use them. |
12/31/2024
| Implemented |
| 6400.213(1)(i) | The individual prep list provided indicated Individual #1's DOA was 2/27/24. The individual rights in the record document the DOA as 8/7/23. An additional document lists the admission date as 7/1/23. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The participant was asked to sign and date onboarding documents by the referring agency before the admission and dated the documents for 7/1/23. The actual admission was 8/7/23 all documents were dated for this date. The participant then relocated to the York Region upon which the new admission date of 2/27/24 was used. This error occurred due the fact that it was not clear to the administration that the admission date remains the same no matter if a transfer to a new region takes place.
The Sr. Admission & Clinical Officer will provide clear onboarding/admissions instructions to the referring provider to leave all dates blank to avoid incorrect dates entered on the admissions form. dates on the form. The participant will sign and date in the presence of personnel. Before finalizing an admission, The PS will review all documents to make sure the admission date is the same on all forms.
There will be a Quality Assurance review by the PD of the participants record after admission and or transfers to ensure that all dates match and regulatory information is in the admission packet. |
10/16/2024
| Implemented |