| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | Screens, windows, and doors shall be in good repair. The screen door arm pump for the screen door located in the basement was unattached to the to screen door. The screen door arm pump was only attached/secured to the doorframe not the screen door at the time of the inspection. The screen located in the basement screen door had a tear in it approximately 3 inches long at the bottom of the screen, and this same screen had a tear on the left side approximately 7 inches long. | Screens, windows and doors shall be in good repair. | Screen door arm pump on the basement screen door was attached to the screen door. The screen was replaced. Attachment # 26, 27 |
03/22/2024
| Implemented |
| 6400.81(k)(4) | Individual #1's bedroom did not have a chest of drawers. | In bedrooms, each individual shall have the following: A chest of drawers. | Chest of drawers was placed in Individual #1's bedroom on 3/22/24. Attachment # 28_ |
03/22/2024
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | Mirror was placed in Individual #1's bedroom on 3/22/24. Attachment # 29 |
03/22/2024
| Implemented |
| 6400.151(a) | A staff person who comes into direct contact with the individuals or who prepares or serves food for more than 5 days in a 6-month period, including temporary, substitute, and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.
Staff #1 had a physical examination on 2/9/2022, and their next physical examination occurred on 3/1/2024.
Staff #2 had a physical examination on 7/21/2021, and their next physical examination occurred on 8/11/2023.
This exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff # 1 current physical occurred on 3/1/2024 and is due for their next physical by 3/1/2026. |
03/21/2024
| Implemented |
| 6400.151(c)(2) | Tuberculin skin testing by Mantoux method with negative results every 2 years.
Staff #1 had Tuberculin skin testing by Mantoux method with negative results on 2/11/2022, and their next one occurred on 3/4/2024.
Staff #2 had Tuberculin skin testing by Mantoux method with negative results on 7/21/2021, and their next one occurred on 8/14/2023.
This exceeds the requirement. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff # 1 current TB occurred on 3/4/2024 and is due for their next TB prior to 3/4/2026. |
03/21/2024
| Implemented |
| 6400.46(a) | Staff #2 did not complete the following required training during training year 7/01/2022 to 6/30/2023: FIRE SAFETY | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff #2 completed fire safety training on 3/14/24. Attachment #30 |
03/14/2024
| Implemented |
| 6400.52(a)(1) | Staff #2 did not complete 24 hours of training during training year 7/01/2022 to 6/30/2023. The staff complete 12 hours of training during the training year reviewed. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff #2 was trained on 55 PA Code Chapter 6400.52(a)(1) on 3/14/24. Attachment # 31 |
03/14/2024
| Implemented |
| 6400.52(c)(1) | Staff #2 did not complete the following required training during training year 7/01/2022 to 6/30/2023: THE APPLICATION OF PERSON-CENTERED PRACTICES, COMMUNITY INTEGRATION, INDIVIDUAL CHOICE, AND SUPPORTING INDIVIDUALS TO DEVELOP AND MAINTAIN RELATIONSHIPS. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #2 will complete the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 3/31/24. |
03/31/2024
| Implemented |
| 6400.52(c)(3) | Staff #2 did not complete the following required training during training year 7/01/2022 to 6/30/2023: INDIVIDUAL RIGHTS | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #2 completed individual rights on 10/21/2023. Attachment # 32. |
10/21/2023
| Implemented |
| 6400.52(c)(4) | Staff #2 did not complete the following required training during training year 7/01/2022 to 6/30/2023: INCIDENT MANAGEMENT | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff #2 will complete incident management on 3/31/24. |
03/31/2024
| Implemented |
| 6400.52(c)(6) | Staff #1 did not complete the following required training during training year 7/01/2022 to 6/30/2023: IMPLEMENTATION OF THE INDIVIDUAL PLAN
Staff #2 did not complete the following required training during training year 7/01/2022 to 6/30/2023: IMPLEMENTATION OF THE INDIVIDUAL PLAN | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff #1 completed Implementation of the individual plan on 3/22/24. Attachment # 33 |
03/21/2024
| Implemented |
| 6400.169(a) | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. The departments medication administration training program annual practicum requirements are two Medication Administration Record (MAR) reviews completed within expected time frame in 1 year period (1 observation every 6 months), and two medication observations completed within expected time frame in 1 year period (1 observation every 6 months). Staff #2 completed their initial medication administration training on 10/20/2021. The next annual practicum for the period of 10/21/2022 to 10/20/2023, has the dates of 7/2023 and 1/2024 (no day of the month was documented) recorded as the dates the medication administration review was conducted, and the same dates, 7/2023 and 1/2024, were recorded as the dates medication administration observations were conducted. The date 1/2024 (no day of the month documented) is beyond the recertification year that ended on 10/20/2023. The medication administration training is not being conducted as required and according to the available documentation, Staff #2 has not been certified to pass medications since the expiration of the initial training on 10/20/2022. The name and initials of Staff person #2 was found on the February 2024 medication administration record (MAR) for Individual #2 and initialed as being the staff who administered medications during that month on at least one occasion to that individual. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #2 will not give medications until he completes the full medication administration course. |
03/22/2024
| Implemented |