| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.101 | There was a padlock on the door leading to the basement of the home posing an obstructed egress when engaged. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | The padlock was removed. |
08/21/2025
| Implemented |
| 6500.121(c)(9) | Individual #1's Prostate-Specific Antigen (PSA) test was done 4/4/24, and there is no record or documentation that the individual completed a prostate exam in April 2025. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The individual was taken for his PSA on 8/16/2025 and will ensure that the individual is taken for all required annual appointments within the timeframes required. |
08/16/2025
| Implemented |
| 6500.124 | Individual #1' is prescribed Pepto Bismol Suspension, 262 mg/15 ml, give 15 ml by mouth as directed PRN. The Pepto Bismol was on Individual #1's August 2025 Medication Administration Record (MAR) however the medication was not in the home at the time of the inspection. | 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. | Provider purchased Pepto Bismol to ensure availability on site. |
08/15/2025
| Implemented |
| 6500.48(b)(2) | There was no record or documentation that Staff #1 received annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act and the Adult Protective Services Act in the 2024 training year. | The annual training hours specified in subsection (a) 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. | Provider completed Prevention, Detection, and Reporting of Abuse on 8/13/2025 |
08/13/2025
| Implemented |
| 6500.135(c) | Individual #1 is prescribed Pain reliever 650 mg caplet, give 1 tablet as directed. At the time of the inspection, what was available and in the home for Individual # 1 was Tylenol Extra Strength 500 mg. | A prescription medication shall be administered as prescribed. | The corrected medication of pain reliever was purchased and the incorrect OTC's were removed. |
08/15/2025
| Implemented |
| 6500.135(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness, and Individual #1 had psychiatric medication reviews on 7/16/25, 4/16/25, 1/13/25, and the 9/10/24 forms used did not include documentation of the medication and the dosage. The form used for each of those dates noted to "see attached", however there was no form or document attached. Individual #1 had psychiatric medication reviews on 7/16/25, 1/13/25, and 9/10/24 the form used did not document the reason for prescribing the medications. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Provider has requested the physical to correct the forms for the dates of 7/16/25, 1/13/25, 9/10/24 |
08/14/2025
| Implemented |
| 6500.136(a)(9) | Individual #1's August 2025 Medication Administration Record (MAR) lists the medication Zolpidem Tartrate 5 mg tablet, take 1 tablet at bedtime. However, the pharmacy label stated Zolpidem Tartrate 5 mg tablet, take 1 tablet by mouth every bedtime as needed (take one tablet at bedtime for insomnia). The MAR and pharmacy label to not match the frequency of administration and are contradictory in direction for administration. The MAR states to administer at bedtime which indicates that it should be administered every day as a daily medication; but the pharmacy label indicates that it should be given on an as needed, or pro re nata (PRN) basis. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The individuals MAR was corrected to reflect the medication PRN and not scheduled. |
08/13/2025
| Implemented |
| 6500.136(b) | The following medication were not initialed on Individual #1's August 2025 Medication Administration Record (MAR) as being administered on 8/8/25 at 8pm: Caltrate 600 Plus, Losartan Pot 25 mg, Zolpidem Tartrate 5 mg, and Valproic Acid 250 mg/5 ml Sol. The medication appeared to be administered as the medication was not in the medication cassette for the 8pm dose on 8/8/25. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Provider will be retrained on medication administration for understanding of clerical errors. |
09/01/2025
| Implemented |