| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(1) | Individual #1 does not have a bed in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. | Program Specialist obtained the newly revised (previously requested) ISP which reflects that Individual 1 prefers not to sleep in a standard bed and that it is acceptable for her to use a futon-style cushion for a bed if she so chooses. |
04/06/2023
| Implemented |
| 6400.81(k)(6) | Individual #1 does not have a mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Program Specialist obtained the newly revised (previously requested) ISP which reflects that Individual 1 prefers not to have a mirror in her bedroom and that not having a mirror is acceptable. |
04/06/2023
| Implemented |
| 6400.112(c) | The written fire drill records for the fire drills held from 6/29/22 to 2/19/23 did not include problems encountered. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | 3/24/23 Maintenance Supervisor updated the LHC Fire drill form to include ¿Problems Encountered¿ and was made available to all service locations. All homes then completed a fire drill using the updated form on or before 3/31/23. |
03/31/2023
| Implemented |
| 6400.142(a) | Individual #1, admitted as emergency respite on 8/26/2022, has not had a dental examination. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Program Specialist scheduled a dental appointment for 4/27/2023 at Aspen Dental in Indian, PA. |
04/27/2023
| Implemented |
| 6400.142(f) | Individual #1, who is not independent in dental hygiene, does not have written plan for dental hygiene. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Program Specialist will create a dental hygiene plan for Individual 1 after the appointment scheduled for 4/27/2023 at Aspen Dental in Indian, PA. The dental hygiene plan as of 4/3/2023 is to attend the first scheduled dental appointment. |
04/27/2023
| Implemented |
| 6400.181(a) | Individual #1, admitted as emergency respite on 8/26/2022, had an assessment completed on 11/30/2022. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The assessment for Individual #1 was completed on 11/30/2022 which corresponded with the date of admission the agency reported for Individual #1 as 10/1/2022. The agency acknowledges an individual placed on emergency respite automatically becomes admitted to the agency as residential habilitation after 31 days on respite, and the date of admission for Individual #1 therefore was prior to 10/1/2022, making the assessment out of compliance. |
04/03/2023
| Implemented |
| 6400.251(b) | Individual #1, admitted as emergency placement on 8/26/2022, has not had a physical examination. | If an emergency placement occurs, § 6400.141 (relating to individual physical examination) shall be met within 31 calendar days after placement.
| Program Specialist scheduled a full physical examination for individual 1 for 5/3/2023 at 10:30AM at ACMH Primary Care Kittanning. |
05/03/2023
| Implemented |
| 6400.34(a) | Individual #1, date of admission 8/26/2022, was informed and explained individual rights on 10/01/2022. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | If an individual is initially placed for respite services, the program specialist will explain individual rights and the process to report a rights violation to the individual and the persons designated by the individual prior to or on the day following the 31st day of receiving respite services. Any person admitted through residential services will have the individual rights explained on the day of admission. |
04/03/2023
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Sertraline HCL, 25mg, take 1 tablet by mouth every morning. Individual #1's March 2023 medication administration record had a handwritten note on a post-it note stating "You can crush the pill and put it in chocolate milk or whatever." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Med Admin updated the MAR for Individual 1 to include the dosage form for Sertraline HCL 25mg. |
04/06/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's March 2023 medication administration record did not include a diagnosis or purpose for Sertraline HCL, 25mg. | 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. | Med Admin updated individual 1 MAR to include diagnosis or purpose for each medication. |
04/06/2023
| Implemented |
| 6400.182(c) | Individual #1's individual support plan, last updated 2/27/2023, does not contain the individual's prescribed medications. Individual #1's assessment completed 11/30/2022 states the individual needs verbal prompting with heat sources. Individual #1's individual support plan, last updated 2/27/2023, does not include ability around heat sources. Individual #2's assessment, completed 8/28/2022, reads the individual needs to be within auditory range throughout the home. Individual #1's individual plan, last updated 3/24/2023, states the individual is able to have 3 hours daily of unsupervised alone time in the home. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program Specialist obtained the newly revised (previously requested) ISP which reflects Individual 1¿s prescribed medications and her support needs around heat sources. 4/5/23 Program Specialist updated Individual 2¿s assessment to reflect 3 hours of alone time which is stated in her current ISP. |
04/06/2023
| Implemented |