| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff member #1's criminal history was not completed for the-new hire date 3/22/21. | 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.
| -Staff Member #1 Employee has received and Completed a Criminal History check.
-This was completed by Human Resources Recruiter. |
12/22/2021
| Implemented |
| 6400.64(a) | The bathtub drain was clogged at point of inspection, and was unable to drain after a test of the water temperature was performed. | Clean and sanitary conditions shall be maintained in the home. | -Work order was input by the Compliance Dept, Work Order was completed by JDB Services . There is no further clogging issues or concerns. |
12/27/2021
| Implemented |
| 6400.65 | The half bathroom has no windows and no operational mechanical vent. The bathroom's light worked at time of inspection, but the vent did not power on with it. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| -Work order was input by the Compliance Dept, Work Order was completed by JDB Services . There is no further ventilation issues or concerns. |
12/27/2021
| Implemented |
| 6400.67(a) | In the primary bathroom, the mirror consisted of two panes of sliding glass; each pane had a hole approximately a half-inch in diameter. One hole was high on the left pane and had a divot or large scratches above and below it; the other was low on the right pane and had no additional scratches or divots around it. The hallway that connected the living room to the bedrooms had a small hole in the wall consistent with the height of the front door's interior doorknob when the door is fully open. The hole was approximately a half-inch in diameter, and the wall around it looked to have been recently patched; also, there was a doorstop panel on the wall near the hole, but not at the height of the doorknob. In individual#1's bedroom, the window across from the bedroom door has blinds that had a broken slat about halfway up the blinds, with the right side of the slat broken off and missing; also six slats around the broken slat had a little over an inch of pinkish-red paint on their right side, the same color as the individual's wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | -Work order was input by the Compliance Dept, Work Order was completed by JDB Services . There are no further holes or scratches that reside in the bathroom glass or panes, holes in the wall in the living room, the patching has been fully completed, a doorstop panel has been applied to the height or the doorknob, blinds have been replaced, paint has been removed from the wall of the individual. |
12/27/2021
| Implemented |
| 6400.72(b) | The screen is damaged in the vacant room's window. A hole about an inch wide was observed toward the lower right corner of the screen. | Screens, windows and doors shall be in good repair. | -Work order was input by the Compliance Dept, Work Order was completed by JDB Services . There is no further damages to the screen in the vacant rooms window. |
12/23/2021
| Implemented |
| 6400.112(f) | All fire drills reviewed list the front door as the exit used for the drill. The property has other access points beyond its front door, namely two garage doors and a back door, accessible through the basement. Drills must vary the access points used. | Alternate exit routes shall be used during fire drills. | -Unannounced Fire Dill was conducted in December using different route in December by DSP staff with Community Home Manager supervision.
-Fire Drill paperwork was reviewed by Program Specialist who concluded different alternate route was utilized. |
12/23/2021
| Implemented |
| 6400.163(e) | Individual#1's epinephrine injection PRN medication was kept locked with their other medications rather than being stored in another safe but more easily accessible location. After the physical site inspection, the agency provided a photo showing the medication had been moved to a kitchen drawer. | Epinephrine and epinephrine auto-injectors shall be stored safely and kept easily accessible at all times. The epinephrine and epinephrine auto-injectors shall be easily accessible to the individual if the epinephrine is self-administered or to the staff person who is with the individual if a staff person will administer the epinephrine. | -PRN Medication was made accessible by Community Home Manager (PRN Medication moved to Kitchen Non-Locked Drawer) |
12/28/2021
| Implemented |
| 6400.165(g) | It cannot be determined that individual#1 has had quarterly psychotropic medication reviews during 2021. A review form dated 1/13/21 was not completed by the doctor, with no recommendations, orders, or a signature filled in. Forms dated 3/31/21 and 4/9/21 both have orders completed, but both have the same 4/9/21 signature date from the doctor. The 6/30/21 review form is complete, but the 9/8/21 review form was not signed by the doctor. An Abnormal Involuntary Movement scale attached to the 9/8/21 review was signed by the doctor as of 9/10/21. The agency must ensure that the medical staff performing psychotropic medication review fully document and sign the review being completed. | 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. | -December 2021 Psych Review Form has been requested to be completed by the Psychiatrist from the Community Home Manager (emails to Physician office for Record, Psych appointment occurred prior to citation from Licensing inspection)
-Psychiatrist office has been refusing to complete 90 Day Form Documentation as requested by the Community Home Manager (emails are included to show evidence)
-March 2021 Psych 90 Day Review(next Psych appointment) will be completed in full by Psychiatrist and Kenccid |
12/27/2021
| Implemented |