| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1 is occasionally incontinent at night and uses incontinence briefs. Financial records show that Individual #1's finances were used to purchase the items on at least two occasions. Receipts dated 10/6/25 and 9/26/25 were noted during a partial review. Incontinence supplies are to be purchased by the provider as part of the room and board paid by Individual #1. | Individual funds and property shall be used for the individual's benefit. | The individual was reimbursed on 10/14/25.
Copy attached.
Complete 10/14/25
The Program Specialist retrained the staff on use of client funds.
Copy Attached.
Complete 12/18/25. |
12/18/2025
| Implemented |
| 6400.82(f) | At the time of inspection there was no toilet paper or clean paper/cloth towels in the bathroom at the front of the home. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Toilet paper and paper towels were placed in the bathroom on 12/11/25.
Photo attached.
Complete 12/11/25 |
12/11/2025
| Implemented |
| 6400.104 | Individual #1 returned from the hospital on 9/3/25 and was temporarily dependent upon a wheelchair due to a fractured femur. Prior to admission Individual #1 had been considered an elopement risk and was able to ambulate and evacuate independently. The last notification to the local fire department was completed on 2/5/25 and noted Individual #1 required only verbal prompts.
A general description of the mobility needs of the individuals served shall be part of the notification and
should be updated when the mobility needs of the individuals served changes. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| An updated letter was completed by the Residential Director and sent to the fire department which includes information on the location of the bedrooms, and the number of individuals who require assistance with evacuation.
Copy attached.
Completed 12/17/25 |
12/18/2025
| Implemented |
| 6400.144 | A memo dated 11/26/25 from the Provider nurse indicated that the following procedures were prescribed by the physician:
"Maintain turning and positioning. Do not keep weight on heels or left buttock for more than 2 hours including while sitting or sleeping and remind him to walk every 45 minutes while awake."
There was no adequate documentation to illustrate that these orders had been followed as written.
Pressure wounds were reported to have been discovered on 10/17/25 and entered into the Enterprise Incident Management (EIM) system as required. Report # 9716227 indicated that tools/charts for staff would be developed that provided clear direction on what staff are required to do to support the prescribed regimen, when to complete it and how they should document the support. This was to be completed as of 11/14/25.
At time of inspection at the home on 12/11/25 the staff in the home were asked how they documented positioning and exercising. They stated that they entered any information into their electronic system and also completed written daily notes. The notes did not adequately document the exercise and positioning prescribed. Staff members were asked if they completed the charts that had been developed to document the information. Staff members stated that they had never seen the chart, were not instructed to use a chart, and were not aware of a chart. | 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.
| The nurse assigned to this home trained staff on 12/18/25 on implementation of the exercise and positioning form. The Manager forwards copies of the completed forms to the Residential Director and QI Department.
Copies attached.
Complete 12/18/25 |
12/18/2025
| Implemented |
| 6400.181(e)(10) | The Assessment for Individual #1 dated 11/7/25 did not include an up-to-date lifetime medical history as required. The lifetime medical history attached was dated 10/17/24. | The assessment must include the following information: A lifetime medical history. | A copy of the current assessment including lifetime medical was sent to the Supports Coordinator on 12/19/25.
Copy attached.
Complete 12/19/25 |
12/19/2025
| Implemented |
| 6400.216(a) | At time of inspection a daily binder was kept on the island counter in the kitchen of the home. The binder contained daily information for the individuals of the home as well as protected information such as hospital discharge instructions from 11/7/25 for Individual #1. Such records should be kept locked when unattended. | An individual's records shall be kept locked when unattended.
| The binder was locked on 12/11/25.
Photos attached.
Complete 12/11/25 |
01/12/2026
| Implemented |
| 6400.18(i) | Incident reports entered into the Enterprise Incident Management (EIM) system on 10/17/25, 10/18/25 and 11/4/25 remained open and without proper extension as of 12/15/25. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | EIM 9716227 was discovered 10/17/25.
The Final Section was due within 30 days by 11/16/25 and submitted one day late on 11/17/25. The incident was open at the time of inspection pending County and Regional Reviews. The County issued a Not approved status on 12/12/25 which kept the incident open until the additional information requested by County Review could be entered.
EIM 9715420 was discovered 10/18/25.
The Final Section was due within 30 days by 11/17/25 and was submitted on time.
The incident was open at the time of inspection pending County and Regional Reviews.
EIM 9725384 was discovered 11/4/25.
The Final Section was due within 30 days by 12/4/25 and submitted on time.
The incident was open at the time of inspection pending County and Regional Reviews.
Copies of Screenshots from EIM are attached. |
01/16/2026
| Implemented |
| 6400.24 | The 1970 Controlled Substances Act requires accurate counts to be kept for controlled substances. Individual #1 is prescribed Lorazepam 2mg. The count sheet in use at the time of inspection included a total of 13 counts from 3/26/25 to 12/9/25. The controlled medication was not counted as required. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Devereux Pocono Center will revise the Medication Administration Procedure to reflect the requirement for incoming and off going staff to count controlled substances, at the beginning and end of each shift, for all residential and day programs. A new controlled substance count sheet has been developed (copy attached) to support this procedure change. A certified Medication Administration trainer will attend IDT meetings at each home and day program and will train staff on the use of the new count sheet. All staff will be trained with a Center wide implementation date of March 31, 2026. |
03/31/2026
| Implemented |
| 6400.32(c) | Per the provider investigators findings related to Enterprise Incident Management (EIM) report # 9716227 "Staff did not consistently document care tasks performed with respect to transferring/repositioning and range of motion exercises being performed. Staff discussed with investigator [Individual #1] reluctance to perform exercises yet did not document in daily shift notes under behaviors. Nursing was notified of broken skin and did not recommend urgent care until approximately 15 hours later. Recommendations from medical providers were not implemented promptly. Examples are discontinuation of wheelchair use on 10/19 and brief use."
In response to the findings, it was noted that staff would begin use of a chart developed to assist in documentation and treatment and to be implemented by 11/14/25. At time of inspection on 12/11/25 documentation of treatment, exercise and positioning was requested and reviewed. The staff in the home were asked how they documented positioning and exercising. They stated that they entered any information into their electronic system and also completed written daily notes. The notes were reviewed and found to not adequately document the exercise and positioning prescribed nor be completed consistently. Staff members were asked if they completed the charts that had been developed to document the information. Staff members stated that they had never seen the chart, were not instructed to use a chart, and were not aware of a chart.
In a shift note report completed on 12/8/25 staff were directed to "Please complete outstanding notes posted with shift reports."
Despite Body Charts being available and noted that completion was needed any time wounds were found only four charts were completed from 10/18/25 through 12/11/25 despite an additional pressure sore being discovered since the 10/18/25 discovery and the other sores remaining. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The nurse assigned to this home trained staff on 12/18/25 on implementation of the exercise and positioning form. The Manager forwards copies of the completed forms to the Residential Director and QI Department.
Copies attached.
Complete 12/18/25 |
12/18/2025
| Implemented |
| 6400.165(c) | A memo dated 11/26/25 from the provider nurse indicated that the Doctor's orders had changed for Individual #1. The memo stated that the orders were now "for the left buttock wound and left heel wound, these are to be done at 10am, daily for both." The December 2025 Medication Administration Record (MAR) for Individual #1 contained entries for the orders of dressing changes and medication administration with assigned times listed as 1:00pm. This was not the reported administration time.
This same memo noted that "Continue Calmaseptine Ointment- Apply a small amount lower left buttock daily for 7 days." At time of inspection the entry for the Calmaseptine, marked as opened on 10/29/25, was administered from 12/1/25-12/11/25 according to the December 2025 MAR. This would extend beyond the stated 7 days.
The pharmacy label on the Calmaseptine indicated that the medication should be administered as "Apply topically 2 (two) times a day (DX: Pressure ulcer of left heel)." According to the December 25 MAR for Individual #1 the medication was being administered once per day and applied to the lower left buttock daily. | A prescription medication shall be administered as prescribed. | Individual #1 has appointments at the wound center every 1-2 weeks. There was a staff error, and previous wound treatments were not discontinued from the MAR when new wound treatments were ordered. The Nurse assigned to the home updated the MAR by discontinuing old treatments and adding new treatments.
Copy of Updated MAR attached.
Complete 12/15/25 |
12/17/2025
| Implemented |
| 6400.166(a)(2) | The name of the prescriber for the following medications was not included on the December 2025 Medication Administration Record for Individual #1:
Hysept0.25% Solution, Xeroform Dressing, Santyl Ointment or Calmoseptine Ointment as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The MAR has been corrected to capture all the required information.
Copy of Updated MAR attached.
Complete 12/15/25 |
12/15/2025
| Implemented |
| 6400.166(a)(8) | The December 2025 Medication Administration Record (MAR) for Individual #1 included two entries for Santyl Ointment. The pharmacy label notes "Apply topically daily measures 3.3cm x 4.5cm x 0.6cm Pressure ulcer of left buttock." One MAR entry notes "Santyl to wound (left heel) cover with 2x2 or 4x4 gauze then abdominal pad. Wrap with gauze; tape closed every day." This entry does not contain the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The MAR has been corrected to capture all the required information.
Copy of Updated MAR attached.
Complete 12/15/25 |
12/15/2025
| Implemented |
| 6400.166(a)(9) | The December 2025 Medication Administration Record (MAR) for Individual #1 included an entry for Hysept0.25% Solution. The pharmacy label states, "Apply 1 application topically daily (DX Pressure Ulcer of left heel)." The MAR notes "Hysept 0.25% to cleanse upper buttock. Pat dry: cover w/ Santyl coated 4x4" and does not include the frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The MAR has been corrected to capture all the required information.
Copy of Updated MAR attached.
Complete 12/15/25 |
12/15/2025
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Ferrous Sulfate, Santyl, Calmoseptine and Xeroform. The December 2025 Medication Administration Record (MAR) for Individual #1 includes entries for the medications but the entries do not include the diagnosis or purpose for the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The MAR has been corrected to capture all the required information.
Copy of Updated MAR attached.
Complete 12/15/25 |
12/15/2025
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Ferrous Sulfate to be administered every other day. The blister pack was dated next to the empty blister for the dose administered at 8am on 12/11/25 but the medication administration record (MAR) was not initialed at the time of administration as required. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The MAR has been corrected to capture all the required information.
Copy of Updated MAR attached.
Complete 12/15/25 |
12/15/2025
| Implemented |
| 6400.186 | The Individual Support Plan (ISP) for Individual #1 last updated on 9/29/25 noted that Individual #1 requires "1-hour checks overnight." It was noted by staff at the home that checks are supposed to be completed every two hours with assigned times of 11-1-3-5 and 7. Daily documentation completed by staff does not indicate that the checks are being completed on a consistent basis at two-hour intervals or one. | The home shall implement the individual plan, including revisions. | Staff were retrained on the individual's supervision levels at the IDT meeting on 12/18/25.
Copy attached.
Complete 12/18/25 |
12/18/2025
| Implemented |