| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | On 4/30/2025 at 11:13PM, the transition strip at the doorway of the kitchen leading from the staff room is not securely flush to the floor and moves at the corners posing a slipping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Provider¿s Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, at 11:13 AM, it was observed that the transition strip at the doorway leading from the staff room into the kitchen was not securely flush to the floor. The strip lifted at the corners, creating a slipping and tripping hazard for staff and individuals in the home.
The transition strip was replaced 2 weeks ago however it was not securely placed.
Corrective Action Taken:
On May 1, 2025, the transition strip was removed and replaced with a new, secure strip that is flush with the floor and free of movement at all corners.
The repair was verified by the Facility Compliance Manager, and photos were taken for the agency¿s maintenance file and compliance verification. |
05/01/2025
| Implemented |
| 6400.72(b) | On 4/30/2025 at 10:26AM, the screen in the window on the right side of Individual #1's bedroom did not securely fit the window and was protruding approximately one inch from the window allowing space for insects to enter the home. There were two, three-inch sections of the window frame that were cracked and broken off next to the screen. On 4/30/2025 at 10:27AM, the screen in the window on the left side of Individual #1's bedroom was bent outward approximately one and a half inches allowing space for insects to enter the home. | Screens, windows and doors shall be in good repair. | Providers Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, during inspection of Individual #1s bedroom, the following was observed:
At 10:26 AM, the right-side window screen was protruding approximately one inch, and the window frame had two cracked and broken sections.
At 10:27 AM, the left-side window screen was bent outward by about one and a half inches, creating a gap that allowed for insect entry.
These issues resulted from gradual damage and lack of timely reporting through the agencys maintenance system.
Corrective Action Taken:
Both window screens were repaired to ensure they fit securely and eliminate any gaps.
The right-side window was measured for a full replacement, and the order has been placed.
The estimated delivery and installation timeframe is 3/4 weeks.
The Facility Compliance Manager has verified the screen repairs, and photos of the completed work are on file. |
06/20/2025
| Implemented |
| 6400.101 | On 4/30/2025 at 10:42AM, there was a turn lock with a keyed locking mechanism on the garage side of the door between the basement and the attached garage; obstructing egress from the garage when engaged. There is no swing door in the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Providers Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, at 10:42 AM, the Licensing Representative observed that the door between the basement and the attached garage had a turn lock with a keyed locking mechanism on the garage side. This configuration obstructed egress from the garage when the lock was engaged, in violation of § 6400.101.
There is no swing door in the garage, and the keyed lock could have delayed or prevented emergency exit.
Corrective Action Taken:
On 5/1/2025 The keyed locking mechanism was immediately removed, and a non-locking knob was installed to allow for unrestricted egress at all times.
The Facility Compliance Manager verified the modification and confirmed the door now meets regulatory standards for emergency exit access. |
05/01/2025
| Implemented |
| 6400.106 | The furnace was inspected and cleaned on 2/1/2024 and then again on 2/18/2025. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Provider¿s Plan of Correction
What Happened / Why It Happened:
The furnace was last inspected and cleaned on February 1, 2024, and then again on February 18, 2025, exceeding the required 12-month interval.
The delay occurred because the agency¿s consistent licensed HVAC contractor was terminated on January 29, 2025, due to an unrelated performance issue. As this occurred during peak heating season, securing a new HVAC provider caused scheduling delays.
Corrective Action Taken:
A new licensed HVAC provider was secured.
The furnace was inspected and cleaned on February 18, 2025.
Documentation of the inspection is on file, and the system is operating safely. |
05/02/2025
| Implemented |
| 6400.110(e) | On 4/30/2025 at 10:45AM, the smoke detectors on each floor of the three-story home were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Providers Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, at 10:45 AM, the Licensing Representative reported that the smoke detectors on each floor of a three-story home were not interconnected, in violation of § 6400.110(e).
However, the smoke detectors at this location had been tested weekly and were functional prior to the inspection. It is believed that during the inspection, the test button on one or more detectors was held down long enough to initiate a reset, which temporarily disabled the interconnected function.
After inspection, the detectors were immediately re-tested, and all alarms were confirmed to be fully interconnected and operational.
Corrective Action Taken:
The Facility Compliance Manager re-tested the alarm system and confirmed full interconnectivity between all floors.
FLS were trained on proper smoke detector testing procedures to avoid accidental resets. |
05/02/2025
| Implemented |
| 6400.141(c)(4) | Individual #1's most recent vision screening was completed on 1/18/2024. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Providers Plan of Correction
What Happened / Why It Happened:
Individual #1s most recent vision screening was completed on January 18, 2024, exceeding the annual requirement.
A previously scheduled appointment was missed due to the failure of ineffective staff to coordinate and attend the visit. This staff member has since been terminated for performance-related reasons, including failure to follow through with medical appointments.
Corrective Action Taken:
The individuals vision screening was successfully completed on May 22, 2025.
The screening report has been added to the individuals record, uploaded into Therap, and shared with the Program Specialist for follow-up |
05/22/2025
| Implemented |
| 6400.216(a) | On 4/30/2025 at 11:15AM, Individual #1's record binder containing personal, identifying information including physical examinations, service plans, assessments and more was unlocked and accessible on top of a cabinet in the staff room with no door. | An individual's records shall be kept locked when unattended.
| Providers Plan of Correction
What Happened / Why It Happened:
On April 30, 2025, at 11:15 AM, the Licensing Representative observed that Individual #1s record binder, which included personal and identifying information (such as physical exams, service plans, and assessments), was left unlocked and accessible on top of a cabinet in the staff room.
The staff room did not have a door, and the record was not stored in a secured location, as required under § 6400.216(a).
Corrective Action Taken:
The individuals record was immediately relocated to the designated locked office within the home.
All staff at the site were re-trained on the importance of records must be secured at all times when not in use.
A lockable file storage system within the home office was verified as operational and assigned for storing all records going forward. |
05/02/2025
| Implemented |
| 6400.44(b)(2) | Chief Executive Officer/Program Specialist #1 did not attend Individual #1's plan team meeting on 1/27/2025. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | Providers Plan of Correction
What Happened / Why It Happened:
The Program Specialist did not attend Individual #1s plan team meeting on January 27, 2025, due to an internal scheduling oversight .
Corrective Action Taken:
The Program Specialist will attend all ISP meetings moving forward.
The Program Specialist will complete the ISP: Beyond Compliance training on MyODP. |
05/30/2025
| Implemented |
| 6400.46(c) | Direct Service Worker #2's, date of hire 6/27/2024, started working with individuals 7/08/2024, and was trained in first aid techniques on 10/31/2024. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Providers Plan of Correction
What Happened / Why It Happened:
Direct Service Worker #2 was hired on June 27, 2024, and began working with individuals on July 8, 2024. First Aid training was completed in two parts:
First Aid #1 July 18, 2024
First Aid #2 July 24, 2024
This means the employee began providing direct support before completing required First Aid training, which is a violation of § 6400.46(c).
The oversight occurred due to a failure in verifying certification status during onboarding.
Corrective Action Taken:
A revised onboarding checklist is now used to confirm that First Aid and CPR training are completed and documented prior to any direct care assignments.
The checklist must be signed by both the Program Specialist and the HR Coordinator before a new hire may be placed on the schedule.
The HR Coordinator was retrained on May 21, 2025, to ensure this process is consistently followed. |
05/21/2025
| Implemented |
| 6400.50(a) | Direct Service Worker #2's, date of hire 6/27/2024, record of orientation did not include the training source and content. Direct Service Worker #3's, date of hire 1/30/2025, record of orientation did not include the training source and content. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Providers Plan of Correction
What Happened / Why It Happened:
The orientation records for Direct Service Worker #2 (DOH 6/27/2024) and Direct Service Worker #3 (DOH 1/30/2025) did not include the training source and content, in violation of § 6400.50(a).
This was due to an administrative oversight during the onboarding process.
Corrective Action Taken:
A new onboarding checklist has been implemented to require documentation of both the training source and content for all new hires.
The Human Resources Coordinator was trained on the updated checklist on May 21, 2025.
Printed Relias certifications are now required to be placed in all new hire files.
A copy of the Relias source content is maintained on-site for compliance review. |
05/21/2025
| Implemented |
| 6400.51(b)(1) | Direct Service Worker #2's, date of hire 6/27/2024, was trained in the application of person-centered practices on 7/25/2024. Direct Service Worker #2's, date of hire 6/27/2024, was trained in community integration on 12/29/2024. | 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. | Providers Plan of Correction
What Happened / Why It Happened:
Direct Service Worker #2 (DOH: 6/27/2024) was cited for missing documentation related to person-centered practices and community integration training.
However, the Relias transcript confirms that:
Community Integration was completed on 6/27/2024
Person-Centered Practices was completed on 7/25/2024
Community Integration was completed again on 12/29/2024
It appears a second page of the transcript may not have been reviewed during inspection, which led to the citation.
Corrective Action Taken:
The full Relias transcript, including all pages, has been printed and filed in the employee¿s personnel record.
The onboarding checklist has been updated to include a verification step for multi-page training transcripts.
All recent hire files are currently being audited for full transcript inclusion and topic compliance. |
06/13/2025
| Implemented |
| 6400.51(b)(2) | Direct Service Worker #2's, date of hire 6/27/2024, was trained in prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 12/29/2024. | The orientation 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. | Providers Plan of Correction
What Happened / Why It Happened:
Direct Service Worker #2 (DOH: 6/27/2024) was cited for not having timely documentation of training on the prevention, detection, and reporting of abuse.
A review of the Relias transcript confirms the employee completed Preventing, Identifying, and Responding to Abuse and Neglect on July 25, 2024, which satisfies the regulatory requirement.
The citation may have been based on the second, duplicate completion dated December 29, 2024, and/or the reviewer not seeing the full transcript.
Corrective Action Taken:
The July 25, 2024 training date has been verified and printed from Relias and placed in the employees file.
The training title, source, and completion date are now clearly documented on the new training compliance checklist. |
06/13/2025
| Implemented |
| 6400.51(b)(3) | Direct Service Worker #2's, date of hire 6/27/2024, was trained in individual rights on 12/29/2024. | The orientation must encompass the following areas: Individual rights. | Providers Plan of Correction
What Happened / Why It Happened:
Direct Service Worker #2 (DOH: 6/27/2024) was cited for not completing orientation on individual rights within the required 30-day period.
However, upon review of the Relias training transcript, it was confirmed that the employee completed the course titled Individual Rights on July 25, 2024 which falls within the 30-day requirement.
The citation appears to have been based on a second, duplicate completion listed as 12/29/2024, or incomplete review of the transcript during inspection.
Corrective Action Taken:
The correct training date of July 25, 2024 has been verified and a printed copy of the Relias transcript was added to the employees personnel file.
The onboarding documentation for the employee has been updated to clearly reflect the correct completion date and training title. |
06/13/2025
| Implemented |
| 6400.51(b)(4) | Direct Service Worker #2's, date of hire 6/27/2024, was trained in recognizing and reporting incidents on 10/30/2024. | The orientation must encompass the following areas: recognizing and reporting incidents. | Providers Plan of Correction
What Happened / Why It Happened:
Direct Service Worker #2 (DOH: 6/27/2024) was cited for not completing training on recognizing and reporting incidents within the required 30 days of hire.
Upon reviewing the employees Relias transcript, it was confirmed that:
"Incident Investigations in IDD" was completed on July 18, 2024
"Writing Incident Reports" was completed on July 25, 2024
Both courses were completed within 30 days of hire and fulfill the intent of § 6400.51(b)(4).
The incorrect date of October 30, 2024 was likely based on an additional or duplicate course, and the earlier, compliant completions may not have been reviewed during the inspection.
Corrective Action Taken:
The Relias transcript with July training dates has been printed and placed in the employees file.
The onboarding documentation was updated to reflect the accurate course titles and completion dates for incident-related training. |
06/13/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #2's, date of hire 6/27/2024, was not trained on the individual plans for the individuals the staff works with directly. | The orientation must encompass the following areas: Job-related knowledge and skills. | Providers Plan of Correction
What Happened / Why It Happened:
Direct Service Worker #2 (DOH: 6/27/2024) did not have documented training on the individual support plans (ISPs) for the individuals they were assigned to work with.
This was due to a breakdown in the onboarding process where individual-specific ISP training was not provided or verified prior to the employee working directly with individuals.
Corrective Action Taken:
The Program Specialist has since trained the staff on the required individual ISPs, and the documentation has been signed and filed in the employees personnel record.
The onboarding checklist has been updated to include a required section for ISP training, including signature of both staff and Program Specialist. |
06/13/2025
| Implemented |
| 6400.166(a)(4) | Individual #1's April 2025 Medication Administration Record did not include the name of Retin-A Cream, Differin Gel and Clindamycin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Providers Plan of Correction
What Happened / Why It Happened:
During the review of Individual #1s April 2025 MAR, it was cited that the names Retin-A Cream, Clindamycin, and Differin Gel were not listed.
However, internal review confirms that Differin Gel was correctly listed on the MAR.
The medications Retin-A Cream and Clindamycin were discontinued on 1/29/2025, but the discontinuation was not clearly documented in the file submitted or reflected in the backup documentation.
This led to confusion during the inspection and contributed to the citation.
Corrective Action Taken:
Differin Gel was verified to be accurately documented on the April MAR.
Retin-A and Clindamycin were confirmed discontinued as of 1/29/2025, and all physical medications were removed from the home.
All staff were retrained on the policy to immediately discard discontinued medications and document the discontinuation on the MAR.
A review of all other program sites was completed to ensure no discontinued medications remained. |
05/30/2025
| Implemented |
| 6400.166(a)(5) | Individual #1's April 2025 Medication Administration Record did not include the strength of Retin-A Cream, Differin Gel and Clindamycin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Providers Plan of Correction
What Happened / Why It Happened:
During the review of Individual #1s April 2025 MAR, it was cited that the strengths of Retin-A Cream, Differin Gel, and Clindamycin were not listed.
Upon review, it was confirmed that Retin-A and Clindamycin were discontinued on 1/29/2025 and should not have been included in the April MAR. Their omission from the April record was appropriate due to discontinuation.
Differin Gel remained active and was listed on the MAR with the appropriate strength, but the discontinued medications' prior absence of strength details was noted as a documentation issue prior to their removal.
Corrective Action Taken:
Retin-A Cream and Clindamycin were discontinued on 1/29/2025, and were not administered or documented on the April MAR.
All staff were retrained on ensuring that all active medications listed on the MAR include the full name, strength, and dosage prior to administration. |
05/30/2025
| Implemented |
| 6400.166(a)(6) | Individual #1's April 2025 Medication Administration Record did not include the dosage form of Retin-A Cream, Differin Gel and Clindamycin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Providers Plan of Correction
What Happened / Why It Happened:
Individual #1s April 2025 MAR was cited for missing the dosage forms of Retin-A Cream, Differin Gel, and Clindamycin.
Upon review:
Retin-A Cream and Clindamycin were discontinued on 1/29/2025 and were not included on the April MAR.
Differin Gel was properly documented on the April MAR, with dosage form clearly listed as:
DIFFERIN 0.1% GEL - Other, Topical, Scheduled (Treatment)
The citation appears to have resulted from a misunderstanding or oversight in review of the Differin entry.
Corrective Action Taken:
No corrections were needed for Differin, as the dosage form was properly listed.
Staff were retrained on the importance of ensuring that dosage forms are clearly entered for all medications, even if they are topical or non-oral.
All homes were checked to ensure no discontinued medications (like Retin-A and Clindamycin) were present, and all discontinued meds were properly removed and documented. |
06/13/2025
| Implemented |
| 6400.166(a)(7) | Individual #1's April 2025 Medication Administration Record did not include the dose of Retin-A Cream, Differin Gel and Clindamycin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Providers Plan of Correction
What Happened / Why It Happened:
During review of Individual #1s April 2025 MAR, it was cited that the dose (amount) for Retin-A Cream, Differin Gel, and Clindamycin was not documented.
Upon internal review:
Retin-A Cream and Clindamycin were discontinued on 1/29/2025, and were no longer active or included in the April MAR.
Differin Gel was properly listed on the April MAR with instructions to Apply topically to face at bedtime for acne and the dosage strength was listed as 0.1% Gel, but the specific amount (dose) applied was not clearly defined (e.g., pea-sized amount or 1 application¿).
Corrective Action Taken:
Staff were retrained on the importance of documenting both the strength and the specific dosage/amount to be administered or applied.
The MAR entry for Differin Gel has been updated to include a clearly defined dose (e.g., Apply pea-sized amount topically to face).
Discontinued medications (Retin-A and Clindamycin) were verified as removed and documented in the discontinuation log. |
06/13/2025
| Implemented |
| 6400.166(a)(8) | Individual #1's April 2025 Medication Administration Record did not include the route of administration of Retin-A Cream, Differin Gel and Clindamycin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Providers Plan of Correction
What Happened / Why It Happened:
During the review of Individual #1s April 2025 MAR, it was cited that the route of administration for Retin-A Cream, Differin Gel, and Clindamycin was not documented.
Upon internal review:
Retin-A Cream and Clindamycin were discontinued on 1/29/2025, and were not listed on the April MAR.
Differin Gel was listed on the April MAR in Therap, and the route of administration (Topical) was properly recorded.
The citation appears to have resulted from a misunderstanding or partial review of the Therap MAR.
Corrective Action Taken:
The April 2025 MAR was reviewed, and it was confirmed that Differin Gel included the route "Topical".
Staff were retrained to ensure that all medication entries in Therap include clearly defined routes of administration, even for discontinued medications prior to removal.
Discontinued medications were verified to be removed and documented appropriately in all homes. |
06/13/2025
| Implemented |
| 6400.166(a)(9) | Individual #1's April 2025 Medication Administration Record did not include the frequency of administration of Retin-A Cream, Differin Gel and Clindamycin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Providers Plan of Correction
What Happened / Why It Happened:
During review of Individual #1s April 2025 MAR, it was cited that the frequency of administration for Retin-A Cream, Differin Gel, and Clindamycin was not included.
Internal review confirmed the following:
Retin-A Cream and Clindamycin were discontinued on 1/29/2025 and were no longer active as of April 2025.
Differin Gel was properly documented in Therap, including a scheduled frequency of 1x daily at 8:00 PM as per the MAR entry.
The citation appears to be based on a misinterpretation or incomplete review of the Therap MAR where frequency was correctly entered for Differin but not visible on printed summary.
Corrective Action Taken:
The April 2025 MAR from Therap was reviewed and confirmed to reflect accurate frequency for Differin Gel.
Staff were retrained to ensure frequency is clearly documented in the MAR system for all medications, including those applied topically.
A full medication audit was conducted to verify there are no active medications across homes lacking frequency details. |
06/13/2025
| Implemented |
| 6400.166(a)(10) | Individual #1's April 2025 Medication Administration Record did not include the administration times of Retin-A Cream, Differin Gel and Clindamycin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Providers Plan of Correction
What Happened / Why It Happened:
During the review of Individual #1s April 2025 MAR, it was cited that the time of administration for Retin-A Cream, Differin Gel, and Clindamycin was not included.
Internal review found that:
Retin-A Cream and Clindamycin were discontinued on 1/29/2025 and therefore were not listed on the April MAR.
Differin Gel was listed on the April 2025 MAR in Therap, and the administration time was accurately documented as 8:00 PM, with a frequency of 1x daily.
This indicates the medication administration time was properly entered in Therap, and the citation may have been due to a misinterpretation of the MAR printout or format.
Corrective Action Taken:
The April MAR for Individual #1 was reviewed and confirmed to reflect correct administration time for Differin Gel.
The Program Manager reviewed all active MARs to ensure that administration times are entered and visible in both Therap and print formats.
Staff were retrained on ensuring time of administration is clearly documented and consistent across all systems. |
06/13/2025
| Implemented |
| 6400.166(a)(11) | Individual #1's April 2025 Medication Administration Record did not include the diagnosis or purpose of Retin-A Cream, Differin Gel and Clindamycin. | 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. | Providers Plan of Correction
What Happened / Why It Happened:
During review of Individual #1s April 2025 MAR, it was cited that the diagnosis or purpose for Retin-A Cream, Differin Gel, and Clindamycin was not documented.
Internal review confirmed:
Retin-A Cream and Clindamycin were discontinued on 1/29/2025, and therefore were not included on the April MAR.
Differin Gel was documented on the April 2025 MAR in Therap, and the purpose was listed as Acne, which meets regulatory requirements.
The citation appears to have resulted from an oversight during the MAR review process or incomplete visibility of Therap documentation during the licensing inspection.
Corrective Action Taken:
The MAR entry for Differin Gel was verified to include the diagnosis Acne as the purpose of use.
Staff were retrained to ensure all medications entered in Therap have an associated diagnosis or purpose field completed.
A review of all active MARs across homes was conducted to verify consistency and accuracy of diagnosis entries. |
06/13/2025
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Retin-A 0.025% Cream with instructions to, "apply topically to face at bedtime for acne," Clindamycin 1% Lotion with instructions to, "apply topically to face two times a day for acne," and Differin 0.1% Gel with instructions to, "apply topically at bedtime for acne." These medications are not included on Individual #1's April 2025 Medication Administration Record. There is no documentation to verify these medications were administered from 4/1/2025 through 4/29/2025. | Medication errors include the following: Failure to administer a medication. | Providers Plan of Correction
What Happened / Why It Happened:
Retin-A Cream and Clindamycin Lotion were discontinued on January 29, 2025 and were no longer active or required during April 2025.
Differin 0.1% Gel remained active, and was included on the April 2025 MAR in Therap.
Therap documentation confirms that Differin was administered and recorded for all 30 days of April.
The citation appears to have resulted from a partial or incomplete review of the Therap MAR by the licensing representative.
Corrective Action Taken:
The full Therap MAR for April 2025 has been reprinted and submitted to verify complete documentation of medication administration.
Documentation of the January 29, 2025 discontinuation of Retin-A and Clindamycin was added to the individual's file and is available for verification. |
06/13/2025
| Implemented |
| 6400.213(7) | Individual #1's record did not include the invitation letter for the service plan meeting held on 1/27/2025. | Each individual's record must include the following information: Individual plan documents as required by this chapter. | Providers Plan of Correction
What Happened / Why It Happened:
An email was located in the individual's chart showing that the invitation letter was requested from the Support Coordinator (SC), and it was subsequently received. However, a copy of the actual invitation was not properly filed in the individual's record at the time of the inspection, which led to the citation.
Corrective Action Taken:
The invitation letter was obtained from the SC and added to Individual #1s record.
The Program Specialist reviewed all individual files to verify that invitation letters from SCs were present and filed properly.
The Program Specialist was retrained on 5/22/2025 to request invitation letters from SCs at least two weeks prior to the ISP meeting. |
06/13/2025
| Implemented |