| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | This provider failed to adhere to its policy/procedures outlined in CADES Infectious Disease Manual, effective 6/30/24-July 1, 2026, which states the following,
"Exclude any students, adult participants in ADP/CLA, and staff with a scabies infestation from time of identification until 24 hours after treatment has started."
The licensing and program staff were allowed in this home by staff on duty staff #1 and Staff #2 and the manager staff #3 that was contacted upon our arrival before the inspection started. Neither the staff on site, nor the manager disclosed that there was scabies in the home. It was not until midway through the inspection another staff member, Staff #4 arrived and advised of the scabies infection in the home. He stated he administered the first treatment on the day of the inspection, while we were there, and the diagnosis was made days prior to the inspection. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | This provider failed to adhere to its policy/procedures by failing to inform visitors in the home on 10/11/24, upon entry into the home of a contagious illness present in the house. The staff were retrained in the infection control policy to ensure that they align with the policy in their actions moving forward and to immediately alert any visitors to the home that a person with a contagious illness is present. |
12/13/2024
| Not Implemented |
| 6400.62(a) | Kitchen cleaner named "Fantastik" was found under the kitchen sink, unlocked and atop the toilet bowl, unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | CADES failed to ensure the health and safety of the individuals at Norwinden by failing to lock cleaning products that are considered poisonous. It is essential that all poison materials and cleaning products be kept locked as indicated in the ISP. These items were removed and locked to ensure the health and safety of the residents at the home. |
10/11/2024
| Not Implemented |
| 6400.64(b) | Soiled bug traps with dead bugs were found in the basement. | There may not be evidence of infestation of insects or rodents in the home. | CADES failed to ensure hygienic and sanitary conditions free and safe from insects or rodents by having soiled traps with insects, in the basement of the Norwinden home. Traps should be disposed of and replaced timely and checked regularly to maintain sanitary conditions in the home. Traps were removed and replaced. |
10/11/2024
| Not Implemented |
| 6400.112(d) | On 10/30/2024 I went to observe a fire drill at this home. The home was actually having a fire and staff moved quickly to evacuate everyone. I was able to time the evacuation, and it did exceed the 2 ½ minute time allowed, it took 2 minutes and 38seconds. My real concern is there were 3 staff on and on the overnights, there are only 2 staff. There is no way staff can evacuate all three individuals in 2 ½ minutes, so alternatives need to be considered. | 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. | This fire resulted in a relocation for the residents of this home on 10/30/24. All three individuals were immediately moved to a temporary site (Barren) while Norwinden is repaired. One of the three was permanently relocated to a new residential site (Rose Valley) on 10/31/24. The temporary site (Barren) had a fire drill on 10/30/24 involving all three individuals with an evacuation time of 50 seconds and another fire drill on 11/27/24 involving the two individuals temporary place with an evacuation time of 2 minutes and 15 seconds. The new permanent site (Rose Valley) had a fire drill on 10/31/24 with an evacuation time of 2 minutes and 17 seconds and a fire drill on 11/4/24 with an evacuation time of 2 minutes and 1 second (Attachment #1). |
11/27/2024
| Implemented |
| 6400.141(c)(4) | No record of dental visit or eye doctor visit provided in the past year for individual #1. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | This paperwork was found following the audit, but it had not been uploaded into the electronic health record correctly. The Dental Appointment was on 6/24/24 and the Vision appointment was on 4/12/24. These documents have been uploaded correctly into the electronic health record. Target date 11/13/24. |
02/28/2025
| Not Implemented |
| 6400.141(c)(10) | Individual #2's Annual physical isn't indicating free from communicable diseases or not and presents as a medical history summary, signed 1/30/2024 with an evaluation on 12/23/2024 which appears to be written in error as 12/22/2024. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | 1. The physical dated 1/30/24 does indicate individual #2 is free from communicable disease. Completion date 1/30/24.
2. There are inconsistencies in the dates included on the annual physical and Lifetime Medical History. This issue cannot be resolved for the current citation, but is addressed as a maintenance plan. |
12/31/2024
| Not Implemented |
| 6400.142(a) | No record of dental visit or eye doctor visit provided in the past year for individual #1. | 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. | This paperwork was found following the audit, but it had not been uploaded into the electronic health record correctly. The Dental Appointment was on 6/24/24 and the Vision appointment was on 4/12/24. These documents have been uploaded correctly into the electronic health record. Target date 11/13/24. |
02/28/2025
| Not Implemented |
| 6400.216(a) | Program books are being left unattended in a space that does not have a door with a lock. | An individual's records shall be kept locked when unattended.
| CADES did not ensure confidentiality and privacy for residents by failing to safeguard personal information specific to their care in an open space in the home. All confidential and protected information must be kept securely out of view in a locked space. The books were moved to the locked closet on 10/11/24 to ensure confidentiality and privacy for the residents in the home. |
10/11/2024
| Not Implemented |
| 6400.169(a) | Staff #5's Required observations not occurring within the six-month time frame as prescribed by Med Admin Training curriculum. Six-month MAR reviews occurred 11/14/2023, 8/16/2024 after initial certification of 4/12/2023 which is outside of the six-month requirement windows. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | All staff must be in compliance with ODP medication administration. Any staff not in compliance will be removed from administering medication.
CADES removed staff 5 from the schedule for medication administration until retraining can take place. |
10/11/2024
| Not Implemented |