| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | The sliding glass door leading from the living room out to the front patio was obstructed by a metal break in bar. The metal bar was attached to the door frame on the right side and was lowered into position on the left side. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The metal break in bar was removed during the inspection on August 3, 2023, once it was pointed out by the inspector. |
08/03/2023
| Implemented |
| 6400.141(c)(1) | Individual #1's annual physical examination, completed on 2/9/2023, did not include a review of the individual's previous medical history. This section was omitted from the physical form template. Individual #2's initial physical examination, completed on 4/15/2023, did not include a review of the individual's previous medical history. This section was omitted from the physical form template. | The physical examination shall include: A review of previous medical history. | We have contacted the SCs for both individual #1 and individual #2 and requested previous medical history to be added to their files. We are awaiting the information to be sent to us. Additionally, we have reviewed the previous medical history with both individual #1 and Individual #2. |
08/18/2023
| Implemented |
| 6400.145(1) | The agency's Emergency Medical Plan, updated 6/2023, does not include the hospital or source of health care that will be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | A copy of our Emergency Medical Policy was submitted when initially requested prior to our actual inspection on August 3, but did not send the corresponding Emergency Medical Sheets for each individual served. Our policy states the Emergency Medical Sheet, which lists the preferred hospital (if consumer has identified one) will accompany that individual when going to hospital or otherwise seeking emergency medical care. The nearest hospital to the Home will be added to the Emergency Medical Plan which in this case is UPMC Passavant. |
08/18/2023
| Implemented |
| 6400.181(a) | Individual #1 was admitted on 11/18/2022 and their initial assessment was completed and sent to the plan team on 1/18/2023. | 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 was completed prior, but one day late and was therefore not in compliance. The plan to prevent this same type of violation is described below in the plan to maintain compliance. |
08/16/2023
| Implemented |