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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisons should be locked or made inaccessible. At the time of inspection, the kitchen cabinet under the sink was not locked. This cabinet contained several poisonous items, including bleach, liquid laundry detergent, tide pods, Fabolous cleaning product, Windex, Lysol cleaning spray, and antibacterial sprays. In addition to the items under the sink, there was a bottle of great value all purpose cleaner spray with bleach on the kitchen counter. All poisons shall be locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Prior to the inspection being completed on 11/2/23, this provider¿s group home supervisor, Program Specialist, and Operations Director ensured that all poisons in the home were immediately locked and away from the individuals. |
12/01/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature was taken several times at this residence and were all greater than 130 degrees. The last reading was 132.4 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 55 PA Code Chapter 6400.68(b)
The water temperature was taken several times at this residence and were all greater than 130 degrees. The last reading was 132.4 degrees.
1. The provider will ensure the home¿s hot water temperature does not exceed 120 degrees F.
2. Upon discovery, the provider immediately contacted the contracted HVAC company for emergency service. The water heater was repaired the same day; the heating element was replaced. After repairs were made, the temperature reading was 115 degrees F. Verification of repair has been retained to verify repairs made and the date of repair.
3. To prevent recurrence of this issue, the site¿s supervisor will test the water temperature on a weekly basis. In addition, should any staff feel that site water feels too warm, they will also test the water temperature. Should a water temperature reading exceed 120 degrees F, staff will immediately notify the Site Supervisor. The Site Supervisor will then contact the HVAC company for mechanicals to be evaluated and repaired.
4. The assigned Program Specialist will oversee compliance in this area during weekly site visits for monitoring purposes. The Program Specialist will also test the water temperature to ensure hot water is not exceeding 120 degrees F. The Program Specialist will review site records detailing weekly temperatures taken by the Site Supervisor or site staff. The Residential Coordinator will monitor implementation and compliance of the plan of correction through random onsite visits which occur on monthly basis, at a minimum. Any further areas of non-compliance noted during the onsite visits, specific to running water, will be remedied through mechanical repair and may involve progressive disciplinary steps, if staff fail to test water temperatures and/or report water temperatures that exceed 120 degrees F. |
12/21/2016
| Implemented |
| 6400.141(c)(7) | Individual #2 is 33 years old. On 10/28/2015, it states she was uncooperative for a pelvic exam/PAP test. She didn't have another PAP test until 1/3/2017. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | 55 PA Code Chapter 6400.141(c)(7)
The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.
1. The provider will ensure female consumers (over the age of 18) receive annual physical examinations to include gynecological examinations, including a breast examinations and Pap tests, from a licensed physician. The exception is a physician recommending no or less frequent examinations. In this instance, the Gynecologist did decrease the frequency of the consumer¿s gynecological examination to every two years; program lacked documentation to support the physician recommendation at the time of inspection. Site staff continue to work with consumer to desensitize her to the emotional trauma experienced during the pelvic exam.
2. Upon discovery of the lack of documentation to support the physician¿s recommendation for an every two year frequency for gynecological examination, for reason of emotional trauma experienced by the consumer in question, the assigned Program Specialist contacted the doctor¿s office. An appointment was made to obtain the note, in addition to working with the consumer for desensitization to the pelvic exam process. During this visit on 1/03/2017, the physician was able to calm and reassure the consumer and she successfully had her pelvic and breast exams; she is now compliant for this year.
3. To prevent recurrence of this issue, the site¿s supervisor will carefully review consumer records to ensure physical examination expiration does not occur. The site¿s supervisor, for this consumer specifically, will be a point of support for the consumer during her desensitization to the physician¿s office. The agency nurse will assist consumers and site staff when needed, as a medical support.
4. The assigned Program Specialist will oversee compliance in this area during weekly site visits for monitoring purposes. The Program Specialist will review site records on a weekly basis. The Residential Coordinator will monitor implementation and compliance of the plan of correction through random/scheduled onsite visits which occur on a once-monthly basis, at a minimum. Any further areas of non-compliance noted during the onsite visits, specific to consumer records and physical examination requirements, will be remedied through immediate outreach to physician(s) for examination and may involve progressive disciplinary steps, if staff fail to comply with regulations set forth in Chapter 6400. |
01/03/2017
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | In November 2013, Staff #1 and Staff #2 overheard Staff #3 tell Individual #1 to shut up because she was screaming during a shower. | (a) An individual may not be neglected, abused, mistreated or subjected to corporal punishment.
| In accordance with the 6400 regulations an Abuse Prohibited and a Preventing, Reporting, Investigating, and Incident Management policy were in place at the time of the violation and prior. Included in the policies are The Pennsylvania Code expectations and standards. Policies are trained upon hire and annually thereafter. As a corrective action to the incident the target employee was suspended, retrained and returned to an alternative location. Additional staff retraining was held for the staff members in question who did not report according to the established guidelines. |
03/28/2014
| Implemented |
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