| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff #1 has PA background check but did not indicate if they were a resident of PA for 2 years., and would therefore need an FBI background check. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| 1. The human resources department had Staff #1 complete the Residency Affirmation (Attachment #7).
2. All other New Hire Residency Affirmations were inspected during the licensing inspections and were compliant.
3. To prevent reoccurrence, the Program Director retrained the Director of Human Resources on 6400.21(b) on 7/3/2024 (Attachment #1). |
07/08/2024
| Implemented |
| 6400.65 | The bathroom's fan was not operable, and the bathroom window could not stay open when it was raised. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| 1. A maintenance request was submitted on 7/1/2024 to have the bathroom exhaust fan repaired or replaced. The maintenance department completed the request on 7/1/2024 (Attachment #4 ).
2. The Program Coordinator or Program Director will complete site inspections on all other programs by 7/8/2024 and document compliance with 55 PA Code Chapter 6400.65 on the Modified Licensing Inspection Instrument Score Sheet. All areas of non-compliance will result in a maintenance request to be fixed (Attachment #2). |
07/08/2024
| Implemented |
| 6400.216(a) | The individuals' ISPs were not locked when unattended. | An individual's records shall be kept locked when unattended.
| 1. Corrected during licensing. Management locked the files in a closet during the inspection. The Program Specialist Supervisor added all ISP Training Guides to Credible (EHR). All physical copies of ISPs have been removed from the site (Attachment #5). Physical copies of the individual record will not be stored at the site. All records are stored electronically on the agency EHR-Credible.
2. The Program Coordinator or Program Director will complete site inspections on all other programs by 7/8/2024 and document compliance with 6400.216(a) on the Modified Licensing Inspection Instrument Score Sheet. All areas of non-compliance will result in a maintenance request to be fixed (Attachment #2). |
07/08/2024
| Implemented |
| 6400.167(a)(1) | Hydrogen Peroxide 3% prescribed to individual #1 was not administered on 06/26/24 due to no syringe being available. However, the MAR does note that the medical provider was contacted and late administration on 06/27/24 was approved. | Medication errors include the following: Failure to administer a medication. | 1. Corrected prior to licensing.
2. The Program Coordinator or Program Director will complete site inspections on all other programs by 7/8/2024 and document compliance with 6400.167(a)(1) on the Modified Licensing Inspection Instrument Score Sheet. All areas of non-compliance will result in an EIM Report and employee counseling. (Attachment #2). |
07/08/2024
| Implemented |