| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | At 1:26PM, the mechanical vent in the bathroom of the home was inoperable. There is not a window in the bathroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Chief Executive Officer reviewed the RCG 2023 and the Self-Inspection Declaration Tool. The Property Owner fixed the mechanical vent in the bathroom on 10/31/2024 to ensure it was operable. |
10/31/2024
| Implemented |
| 6400.81(h) | Individual #1's bedroom does not have a window the permits a view to the outside. | Each bedroom shall have at least one exterior window that permits a view of the outside. | The Chief Executive Officer reviewed the RCG on 10/10/2024. Chief Executive Officer informed and educated Individual #1 on room and change and the reason for the room change. The agency changed individual #1's bedroom on 10/10/2024 to the vacant bedroom. |
10/10/2024
| Implemented |
| 6400.141(c)(4) | Individual #1 date of admission, 6/17/24 had an initial vision and hearing screening on 7/10/24. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Chief Executive Officer reviewed the RCG. Chief Executive Officer completed the self-assessment tool on 10/31/2024. Individual #1 vision and hearing screening was completed on 7/10/2024. |
10/31/2024
| Implemented |
| 6400.141(c)(7) | Individual #1 date of admission 6/17/24 had an initial gynecological examination completed on 7/26/24. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Chief Executive Officer reviewed the RCG. A completed Self-Assessment tool was completed on 10/31/2024 to ensure the CEO utilizes the assessment tool for violations that have been corrected. Individual #1 gynecological examination was completed on 7/26/2024. |
10/31/2024
| Implemented |
| 6400.181(e)(12) | Individual #1's initial assessment, completed 8/12/24 did not include recommendations for specific areas of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Recommendations for specific areas of training, programming and services were completed in the assessment for individual #1 by the Chief Executive Officer on 10/31/2024. A Money Management Program was created for individual #1 to help increase money management skills on 10/31/2024. Staff educated through Scomm on new program for individual #1. New program taken to the home on 10/31/2024 for staff to implement program and document. Review of the regulation 6400.181(e)(12) was reviewed by the Chief Executive Officer to ensure the assessments compliant and filled properly to ensure compliancy. A copy of the assessment and Money Management Program will be provided with this Plan of Correction. |
10/31/2024
| Implemented |
| 6400.15(b) | The agency used the "Self-Inspection and Declaration Tool-Increase In Capacity 55 pa. Code Chaper 6400" to measure and record compliance instead of the "Self-Assessment Licensing Instrument 55Pa Code Chaper 6400." | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Chief Executive Officer completed the Self-assessment tool on 10/31/2024 ensure compliancy with regulation 6400.15(b). CEO reviewed the Regulatory Compliance Guide. The CEO has created a 2025 digital and a tangible calendar to ensure The Department's licensing Inspection Tool form will be used 3-6 months prior to the next renewal date. A copy of the 2025 calendar and the Self-Assessment Tool will be provided with the Plan of Correction. |
10/31/2024
| Implemented |
| 6400.51(b)(1) | Direct Service Worker #2, date of hire 5/15/24, did not have orientation in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, until 7/10/24. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Chief Executive Officer reviewed the RCG 6400.51(b)(1). Direct Service Worker #2 completed the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 7/10/2024. CEO completed the Self-Assessment Tool and became educated on the importance of the assessment tool. CEO created an onboarding template to ensure all trainings are completed prior to working alone with an individual. Documentation of the new onboarding form will be provided with this Plan of Correction. |
10/31/2024
| Implemented |
| 6400.52(c)(1) | Chief Executive Officer #1's annual training for training year from 1/1/2023 to 12/31/23, does not encompass 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. | Chief Executive Officer reviewed the RCG 6400.51(b)(1). Chief Executive Office #1 completed the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 10/29/2024 on myodp.org. Verification of training will be provided with this Plan of Correction. |
10/29/2024
| Implemented |
| 6400.52(c)(2) | Chief Executive Officer #1's annual training for training year from 1/1/2023 to 12/31/23, does not encompass the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Chief Executive Officer reviewed the RCG 6400.52(c)(2). Chief Executive Officer #1 complete the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act on 10/29/2024 on myodp.org. A copy of the training will be attached to this Plan of Correction. |
10/29/2024
| Implemented |
| 6400.52(c)(3) | Chief Executive Officer #1's annual training for training year from 1/1/2023 to 12/31/23, does not encompass the individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Chief Executive Officer #1 Completed annual training for individual rights on 10/29/2024 on myodp.org. A review of the above regulation was reviewed by the CEO. A copy of the training certificate will be attached to this Plan of Correction. |
10/29/2024
| Implemented |
| 6400.52(c)(4) | Chief Executive Officer #1's annual training for training year from 1/1/2023 to 12/31/23, does not encompass recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Chief Executive Officer #1 Completed annual training for recognizing and reporting incidents on 10/29/2024. A review of the above regulation was reviewed by the CEO. A copy of the training certificate will be attached to this Plan of Correction. |
10/29/2024
| Implemented |
| 6400.52(c)(5) | Chief Executive Officer #1's annual training for training year from 1/1/2023 to 12/31/23, does not encompass the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Chief Executive Officer #1 Completed annual training for the safe and appropriate use of behavior supports on 10/29/2024. A review of the above regulation was reviewed by the CEO. A copy of the training certificate will be attached to this Plan of Correction. |
10/29/2024
| Implemented |
| 6400.52(c)(6) | Chief Executive Officer #1's annual training for training year from 1/1/2023 to 12/31/23, does not encompass the 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. | Chief Executive Officer #1 Completed annual training for the implementation of the individual plan on 10/29/2024. A review of the above regulation was reviewed by the CEO. A copy of the training certificate will be attached to this Plan of Correction. |
10/29/2024
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication review, completed 9/17/24, did not include the reason for prescribing Buspirone HCL 7.5mg tablet and Risperdal 2mg tablet. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Chief Executive Officer (CEO) created a new 90-day medication review form to include the reason for prescribing the medication, the necessary dosage and the need to continue. The CEO contacted of office of physician in-person with individual #1. Individual #1 had a 90-mediction review but the form did not include the regulatory components. The physician was able to update the form. The Buspirone HCL 7.5mg tablet is prescribed for anxiety and will continue. The Risperdal 2mg tablet is prescribed for schizophrenia. and it's recommended to continue. The CEO updated the MAR to add the reason for prescribing the medication on 11/1/2024. The updated form was placed under the medical section in individual #1's chart. Staff was notified of the change and the protocol for the new form through the Scomm communications. |
11/01/2024
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Buspirone HCL 7.5mg tabs with instructions on the medication label to take 1 tablet twice a day by oral route. Individual #1's October 2024 Medication Record has instructions for the medication to give one ½ tablet twice daily. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The CEO completed the Self-Assessment Tool and reviewed the RCG. The Chief Executive officer update Therap on 10/10/2024. CEO notified staff of the changes. CEO sent a reminder of the medication policy through the Scomm communication. The CEO created a two person sign off sheet a review of new medications check-in. The CEO notified staff of the new protocol through the Scomm system. Medications were reviewed for new MAR in November by the CEO. |
10/10/2024
| Implemented |
| 6400.192 | At 1:19PM, the knives and scissors in the home were being locked in a cabinet in the laundry room. In the health and safety section of Individual #1's Individual Plan, last updated 7/1/24 reads, "All sharp objects need to be locked up due to [Individual #1] prior attempts to harm herself and others. "Sharp objects are also kept locked in the home to ensure the safety of [Individual #1] and others. [Individual #1 is permitted to use butter knives but is not permitted access to anything sharper." The home does not have a restrictive procedure plan for Individual #1. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | The Chief Executive Officer reviewed the RCG 6400.192 for guidance and education. The CEO reviewed individual #1 assessments. The CEO had staff monitor individual#1 meals on 10/22/2024/-10/27/2024 for the utilization of and safety of a knife. Individual #1 was unable to utilize a knife safely. The CEO updated the assessment to reflect the change. The CEO emailed the SCO on 10/28/24 about the change to the assessment and sent a copy of the assessment. The SCO notified the CEO on 10/29/24 that ISP was updated to state, "hurting others is no longer an issue and that knives are kept locked as she does not know how to use them". Staff was notified on 10/29/24 about the change and document when assisting her with utilizing a knife safely and independently. |
10/29/2024
| Implemented |