| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.83(b)-1 | There was no record or documentation that fire alarm was checked in the month of November 2021. | An employe trained in the operation of the equipment shall check the fire alarm monthly. | This was an oversight completed by the person who previously reviewed fire alarm records. The person who previously reviewed this has transferred to another building. Program Specialists will now be taking care of this, and have been trained to ensure this is reviewed monthly. |
09/06/2022
| Implemented |
| 2390.104(4) | Individual #2's and Individual #3's record did not include medical information pertinent to diagnosis and treatment in case of emergency. | Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency. | Staffing inconsistency for Program Specialists have been a challenge at the Bethlehem location. For over a year, there has been only one consistent PS which may have contributed to oversight. Both PS have been trained on reviewing medical information, especially physicals provided by physicians to ensure they are completed in their entirety. |
08/03/2022
| Implemented |
| 2390.151(e)(12) | Individual #1's assessment dated 6/2/22, Individual #2's assessment dated 12/25/21, and Individual #3's assessment dated 9/9/21 did not provide recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | An old assessment form was mistakenly used. Program specialists have been re-trained on the proper form to use for assessments. The new assessment form has a space to document recommendations for specific areas of vocational training or placement and competitive employment. |
08/03/2022
| Implemented |
| 2390.151(e)(13)(iii) | Individual #1's assessment dated 6/2/22, Individual #2's assessment dated 12/25/21, and Individual #3's assessment dated 9/9/21 did not address or assess the individual's progress over the last 365 calendar days and current level in the area of personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | An old assessment form was mistakingly used. Program Specialists were re-trained and provided the assessmment form which documents the individuals progress over the last 365 calendar days and current level in the following areas: personal adjustment. |
08/03/2022
| Implemented |
| 2390.21(u) | Individual #1 was informed of their client rights on 10/16/21, Individual #2 was informed of their rights on 10/26/21, Individual #3 was informed of their rights on 10/29/21, Individual #4's was informed rights until 7/11/22, and Individual #5 was informed of their rights on7/12/22, but the rights have not been updated. The agencies rights haven't been updated to reflect the current Chapter 2390 regulations. The missing rights include client may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment, make choices/accept risks, refusal of activities, privacy of person and possessions, access to and security of possession, voice concerns, negotiate choices, and rights may not be modified in accordance with §2390.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the client or others.( Repeat Violation 10/15/21) | The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter. | The clients watched an individual rights video on their admission day, but all individuals did not have a signed form documenting this. In addition, the current form was revised to include all of the indvidual rights documented on their sign off form. |
08/03/2022
| Implemented |
| 2390.48(b)(3) | Staff #1 date of hire was 5/16/22, Staff #2's date of hire was 6/27/22, and staff #3's date of hire was 6/6/22 and their orientations did not encompass client rights. | The orientation must encompass the following areas: Client rights. | The orientation window has since been completed for the staff members who did have a documentation for individual rights. They have been since been trained and completed the myODP training to ensure they are knowledgable on individual rights for consumers |
08/03/2022
| Implemented |