| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's certificate of compliance expired on 12/06/2021, and the self-assessment was not completed until 3/22/2022, which was not within 3 to 6 months PRIOR to the expiration date of the certificate of compliance. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Training will be completed with Program Specialists by 5/20/2022 regarding 55 PA Code Chapter 6400.15 (a) by having self assessments completed 3-6 months prior to expiration of certification. Attachment # 14 is the completed Self assessment that was completed in the 3-6 month timeframe in 2021. |
05/20/2022
| Implemented |
| 6400.141(b) | The annual physical examination completed on 2/24/2022 not signed and dated by the physician or practitioner who completed the examination. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Annual physical that was completed on 2/24/2022 was sent back to the PCP and the physical was signed on 5/6/2022 Attachment #15. Training will be completed with the Program Specialists to ensure that all medical paperwork including physicals are completed entirely by 5/20/2022. |
05/20/2022
| Implemented |
| 6400.141(c)(6) | Individual #1 had a late Tuberculin skin test by Mantoux method. The most recent Tuberculin testing occurred on 5/07/2022, and the previous testing was on 1/07/2019. | 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. | Program Specialist will be trained by 5/20/2022 on TB testing documentation 55 PA Code Chapter 6400.141 (c )(6) Refer to Attachment #7 |
05/20/2022
| Implemented |
| 6400.141(c)(10) | The annual physical examination for Individual #1 that was completed on 2/24/2022 did not document that the individual is free from communicable disease - the area was left blank on the physical examination form. | 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. | Annual physical that was completed on 2/24/2022 was sent back to the PCP and the physical was signed on 5/6/2022. Training will be completed with the Program Specialists to ensure that all medical paperwork including physicals are completed entirely. Refer to Attachment #15 |
05/09/2022
| Implemented |
| 6400.34(a) | The Individual Rights that were reviewed with and signed by Individual #1 on 12/23/2021 were not updated to include the rights included in the current chapter 6400 regulations. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual Rights Policy has been updated to reflect the current Chapter 6400 regulations of the 55 PA Code Chapter 6400.34 (a) Program Specialist will review most recent Individual Rights Policy with individuals by 5/20/2022. Attachment #16 |
05/20/2022
| Implemented |
| 6400.163(h) | The medication Loperamide Hcl 2mg. caplets, to be administered on a pro re nata (prn) basis for diarrhea. was found in a blister pack located in the medication box. The blister pack label stated that the medication was to be discarded after 3/02/2022, but the medication was still stored with the Individual's current medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Lopermide was discarded in according to Federal and State statues and regulations on 4/6/2022. |
04/06/2022
| Implemented |