| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(e)(11) | Individual #1 content of records did not contain a psychological evaluation, and there was no documentation showing one was requested by the agency. Individual #1's Service Plan, last updated 3/5/26, identified an applicable psychological evaluation that was completed on 1/2/23. | The assessment must include the following information: Psychological evaluations, if applicable. | Supports Coordinator and parents were contacted to obtain the psychological report that was completed on 1/2/2023. The Supports Coordinator could not release the document, but the parents had a copy and submitted it for Individual #1's file. |
05/04/2026
| Implemented |
| 2390.151(e)(12) | Individual #3's current assessment, completed on 6/26/25, did not include specific areas of vocational training or placement and competitive community-integrated employment, as the corresponding field, entitled, "Specific Areas of Vocational Training or Placement and Competitive Community-Integrated Employment," was marked, "N/A." [Repeated Violation-7/1/25] | The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | Individual #3's assessment has been revised to include a narrative regarding specific areas of vocational training or placement and competitive community-integrated employment as follows: Individual #3 worked in a competitive community-integrated employment position in the past. She had the skills for the job, but she didn't have the social skills to maintain it even with the support of her job coach. She knows she is safe and accepted and prefers this environment over the stress of a competitive community integrated position. Individual #3 is challenged to use her skills by working in various areas of the Clelian Center and with different supervisors. Individual #3 has good skills, but when she is concerned about something like her physical health or an upcoming appointment, staff see a decline in the quality of her work. Staff try to get her to discuss what she has on her mind prior to starting work and she is encouraged to use calming oils if she is very agitated or preoccupied about an upcoming event. Lately she has been extremely preoccupied about her cataract surgeries. It is our vocational recommendation that Individual #3 continue to increase her independence and the consistent quality of her work to a level suitable for community employment in the event that she decides to pursue competitive integrated employment in the future. |
05/04/2026
| Implemented |
| 2390.49(c)(2) | Executive Director #1's annual training record for the agency's staff training year from 8/1/24 to 7/31/25 did not include completion of the required content topic on the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse. | 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. | Executive Director #1 completed the PS Mandatory Abuse Reporting Training Course and received a Certificate of Completion. She also watched/read the PA Department of Human Services: Adult Protective Services powerpoint presentation in its entirety and signed a document attesting to it. |
05/04/2026
| Implemented |
| 2390.152(c) | Individual #3's Service Plan, last updated 3/10/26, contained the following discrepancies between their current assessment, completed on 6/26/25, in the following health and safety skill domains: regarding self-administration of medications, Individual #3's Service Plan, last updated 3/10/26, informed that Individual #3 "can take [medications] on [their] own with a visual cue." In contrast, Individual #3's assessment, completed on 6/26/25, stated, "[Individual #3] can self-administer medications without assistance."; and regarding heat sources exceeding 120 degrees Fahrenheit, Individual #3's Service Plan, last updated 3/10/26, explained that Individual #3 is "familiar with heat sources and knows to avoid them." However, Individual #3's assessment, completed on 6/26/25, indicated that Individual #3 needs supervision to understand the dangers of heat sources as well as to sense and quickly move away from such sources. [Repeated Violation-7/1/25] | The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment. | Program Specialist discussed Individual #3's ability to self-medicate with her father and information in the assessment and service plan were both correct. Individual #3 takes her medication independently from her pill bottles some of which are marked with the visual cues of AM and PM. Another medication bottle has no visual cue and she independently knows the time to take that medication. Assessment was updated to reflect both situations. The information in the ISP regarding heat sources exceeding 120 degrees Fahrenheit and Individual #3 being familiar with heat sources and knows to avoid them is correct. The assessment has been corrected to reflect this reality. The assessment has been submitted to the Supports Coordinator to update the medication administration nuances. |
05/04/2026
| Implemented |