| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | At the time of inspection, there were two full trash receptacles in the home's front yard that were not equipped with lids. There was a full plastic trash bag sitting next to the trash receptacles. This trash would be vulnerable to penetration by insects and rodents. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | An additional trashcan with a lid was purchased to ensure appropriate trash receptacles are available in compliance with 55 PA Code Chapter 6400.64(f). Attachment # 18 |
04/03/2023
| Implemented |
| 6400.101 | The sliding glass door in the home's basement was secured shut by a plank of wood that was intentionally placed in the door's sliding track by provider staff. Until the plank of wood was removed from the track, it was not possible to open the door using any amount of bodily force, even if the door's locking mechanism was disengaged. Using the plank of wood to secure the sliding glass door in this manner constitutes an impediment to swift and safe egress from the basement of the home during a fire or other emergency. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Plank of wood was removed from sliding glass doors on 2/28/23. Maintance placed a security bar on 3/10/23 that is designed specially to stop intruders and is approved by the fire marshall and is in compliance with 55 PA Code Chapter 6400.101 which will allow for swift evacuations. Attachment # 19 |
04/03/2023
| Implemented |
| 6400.141(c)(6) | Individual #1's two most recent Mantoux tests took place on 01/11/2019 and 04/01/2022. The interim between these Mantoux tests exceeds the two years permissible under this chapter. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Training will be completed with Program Specialists by 3/24/23 regarding 55 PA Code Chapter 6400.141 (c )(6) and with ensuring that all appointments are completed by the guidelines of the medical providers and state regulations. |
04/03/2023
| Implemented |
| 6400.142(h) | No dental hygiene plan could be located within Individual #1's Individual Record. | The dental hygiene plan shall be kept in the individual's record. | Dental hygiene plan was completed for individual #1. Attachment # 21 |
04/03/2023
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, in the acquisition of functional skills. If the individual has not made any progress in this area since the previous assessment, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, in communication. If the individual has not made any progress in this area since the previous assessment, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, in the area of personal adjustment. If the individual has not made any progress in this area since the previous assessment, then the assessment should explicitly state that no progress has been made. | The individual's current level of performance and progress in the following areas: Personal adjustment. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, in the domain of personal needs with or without assistance from others. If the individual has not made any progress in this area since the previous assessment, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of health. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proProgram Specialists will completed individual annual assessments on an annual basis and will ensure to assess the progress of the individual over the last 365 calendar days. Director of IDD Residential Serivces will run quarterly reports to ensure compliance.
per completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of motor and communication skills. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of activities of residential living. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of personal adjustment. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/04/2023
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of socialization. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of recreation. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of financial independence. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of managing personal property. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's Individual Assessment, dated 11/04/2022, does not contain information regarding the individual's progress, if any, over the last 365 calendar days, in the area of community integration. If the individual has not made any progress in this area, then the assessment should explicitly state that no progress has been made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Individual #1 assessment was updated on 3/14/23. Program Specialists will be trained by 3/24/23 regarding the proper completion of residential individual annual assessment. Attachment #22. |
04/03/2023
| Implemented |
| 6400.32(c) | The following two medications prescribed for Individual #1 were not administered as prescribed: Thick-It Powder and Ensure Plus. The February 2023 Medication Administration Record (MAR) noted omissions of these medication administrations (using the letter "O") in the initial boxes for the following administration times:
1. Thick-It Powder [Use three times a day and as needed for honey-thick consistency] -- 2/22, 2/23, 2/27, 2/28
2. Ensure Plus [1 can by mouth in the morning, noon, and in the evening] - 2/23 at 9pm; 2/24 at 7am, 12pm, & 9pm; 2/25 at 7am, 12pm, & 9pm; 2/26 at 7am, 12pm, & 9pm; 2/27 at 7am
The back of the MAR pages corresponding to these entries notes that staff were "waiting on" each medication in question. When asked what this notation meant, staff on site stated that the pharmacy utilized by the individual did not have these medications in-stock and had to order them. Per staff on site, as the medications were not available in the home, they were not administered to the individual at the above times.
Per Individual #1's Individual Support Plan, dated 02/15/2023, the individual is on a "GLUTEN FREE, LOW FAT, LOW CHOLESTEROL, NO ADDED SALT DIET···LIQUIDS ARE THICKENED WITH THICK-IT. [The individual's] FOOD IS PUREED - NECTAR CONSISTENCY. [The individual] IS PRESCRIBED ENSURE 3X'S/DAY TO ENSURE SHE IS GETTING THE APPROPRIATE NUTRIENTS." The individual was not receiving Ensure Plus three times per day as prescribed on the dates and times outlined above; therefore, it must be concluded that the individual was not receiving adequate nutrition for the dates on which one or more administrations of Ensure Plus were omitted, amounting to neglect of the individual.
A document titled "Individualized Feeding Plan" dated 04/01/2022 and signed by the individual's Primary Care Physician (PCP) notes that the individual is to receive only "honey-consistency" liquids. As the February 2023 MAR indicates that Thick-It Powder was not administered on the dates noted above, it must be concluded that either the liquids provided to the individual on those dates were not prepared to honey-thick consistency as recommended by the PCP or that the individual was not provided with liquids on those dates. Although it cannot be determined which of these two circumstances transpired, the following general conclusion can be drawn: in the first case, the provider would not have been following the individual's recommended dietary restrictions and feeding procedure, constituting neglect of the individual; in the second case, by failing to supply the individual with liquid sustenance throughout the day, the provider would have been neglecting the individual.
In summation, due to the dietary restrictions and feeding procedures recommended by the individual's PCP, the provider's failure to administer the above medications as prescribed also constituted neglect of the individual by the provider. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | An EIM report was initiated on 3/2/2023 and an investigation was started. Outcome is pending. Corrective actions will be implented timely. EIM #9176527 |
04/14/2023
| Implemented |
| 6400.46(d) | Per staff training records, Staff #1 last received training on first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 04/08/2020. This training was conducted through the American Red Cross and is noted to remain valid for a period of two years. As there is no evidence that a more recent training occurred, this staff did not receive training in this area at the annual frequency required under this chapter or at the two-year frequency specified by the American Red Cross. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | HR will enter all current staff's Red Cross Adult First Aid/CPR/AED certification dates into an electronic database, and alert staff 2 months prior to their due dates to ensure compliance of 55 PA Code Chapter 6400.46(d). HR will complete this task by 4/14/2023. |
04/14/2023
| Implemented |
| 6400.165(c) | The following three medications prescribed for Individual #1 were not administered as prescribed: Eucerin Cream, Thick-It Powder, and Ensure Plus. The February 2023 Medication Administration Record (MAR) noted omissions of these medication administrations (using the letter "O") in the initial boxes for the following administration times:
1. Eucerin Cream [Apply to upper and lower extremities twice a day]-- 2/23 at 7am & 7pm, 2/24 at 7am & 7pm, 2/25 at 7am & 7pm, 2/26 at 7am & 7pm, 2/27 at 7am & 7pm, and 2/28 at 7am.
2. Thick-It Powder [Use three times a day and as needed for honey-thick consistency] -- 2/22, 2/23, 2/27, 2/28
3. Ensure Plus [1 can by mouth in the morning, noon, and in the evening] - 2/23 at 9pm; 2/24 at 7am, 12pm, & 9pm; 2/25 at 7am, 12pm, & 9pm; 2/26 at 7am, 12pm, & 9pm; 2/27 at 7am
The back of the MAR pages corresponding to these entries notes that staff were "waiting on" each medication in question. When asked what this notation meant, staff on site stated that the pharmacy utilized by the individual did not have these medications in-stock and had to order them. Per staff on site, as the medications were not available in the home, they were not administered to the individual at the above times.
The inability to obtain medications from a specific pharmacy is not a permissible reason for omitting an administration of medication and does not absolve the provider of their responsibility to administer medications to the individual as prescribed. | A prescription medication shall be administered as prescribed. | An EIM report was initiated on 3/2/2023 and investigation was started. Outcome is pending. Corrective actions will be implented timely. EIM #9176561. A training will be completed with Program Specialist on obtaining medications will be done by 3/24/23. |
04/03/2023
| Implemented |