| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Fire Safety Training completed on 9/24/2024. Individual #1 moved into the home on 9/23/2024. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | The Cohen Health Services Group is committed to ensuring the safety and well-being of all individuals receiving services. In accordance with 55 PA Code Chapter 6400.113(a), which mandates fire safety training and emergency preparedness, the agency will ensure that all participants complete a full fire drill on the first day of admission. |
03/04/2025
| Implemented |
| 6400.141(a) | Incomplete physical in the record, dated on 7/22/2024 that is missing several regulatory factors that should be included on a physical such as dietary restrictions, whether the individual is free from communicable diseases and allergies for Individual #1. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A New Participant Move-in Checklist will be implemented to ensure all required fields are completed before accepting any physical examination form into an individual's record. Any physical examination form found to be incomplete will be returned to the physician for correction before acceptance into the agency's records. * See Attachment #2 (New Participant Move-in Checklist). |
03/04/2025
| Implemented |
| 6400.151(c)(3) | Physician failed to check box yes or no to indicate whether Staff Person #1 is free from communicable diseases on physical dated 9/22/2023. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The agency's Human Resources department will verify that all staff physical examination forms include a completed communicable disease section before they are approved to work with a participant. Any incomplete physical form will be returned to the physician for correction before employment clearance. A New Employee Onboarding Checklist will be used to confirm that all required fields on the physical examination form are completed before onboarding. *See Attachment #1 (New Employee Onboarding Checklist) |
03/04/2025
| Implemented |