| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Per Individual #1's most recent assessment updated on June 27, 2024, Individual #1 is not financially independent. There are no current and up-to-date financial ledgers for petty cash or Snap Benefits available at the home for individual #1. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The Financial Director and program manager are responsible for fixing this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received.
Though funds were not received for individual
The agency has implemented changes to its overall financial accounting for residents. New binders have been placed at individuals' homes. The binders contain a "Money received form" and transaction forms that require staff to attach receipts and fill in descriptions of transactions and reflect a point-in-time balance.
The binder would have sections for EBT, Cash, and cards. In some cases, the individual refuses to give a receipt, so the staff must indicate on the transaction form that the individual refused to give a receipt. In other cases, the family or individual would not inform the agency of any disbursements made to them. In such cases, the transaction receipt would only reflect the transaction but no end or beginning balance.
This process was implemented on 10/14/2024 |
10/14/2024
| Implemented |
| 6400.22(d)(2) | Per Individual #1's most recent assessment updated on June 27, 2024, Individual #1 is not financially independent. There are no current and up-to-date financial ledgers for petty cash or Snap Benefits available at the home for individual #1. | (2) Disbursements made to or for the individual.
| The Financial Director and program manager are responsible for fixing this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received.
Though funds were not received or disbursed for individual
The agency has implemented changes to its overall financial accounting for residents. New binders have been placed at individuals' homes. The binders contain a "Money received form" and transaction forms that require staff to attach receipts and fill in descriptions of transactions and reflect a point-in-time balance.
The binder would have sections for EBT, Cash, and cards. In some cases, the individual refuses to give a receipt, so the staff must indicate on the transaction form that the individual refused to give a receipt. In other cases, the family or individual would not inform the agency of any disbursements made to them. In such cases, the transaction receipt would only reflect the transaction but no end or beginning balance.
This process was implemented on 10/14/2024 |
10/14/2024
| Implemented |
| 6400.22(e)(3) | On September 7, 2024, Individual #1 spent $25. There was no receipt available for this transaction. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The Financial Director and program manager are responsible for fixing this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received.
Though family directs the individual not to release receipts to staff, The agency has implemented changes to its overall financial accounting for residents. New binders have been placed at individuals' homes. The binders contain a "Money received form" and transaction forms that require staff to attach receipts and fill in descriptions of transactions and reflect a point-in-time balance.
The binder would have sections for EBT, Cash, and cards. In some cases, the individual refuses to give a receipt, so the staff must indicate on the transaction form that the individual refused to give a receipt. In other cases, the family or individual would not inform the agency of any disbursements made to them. In such cases, the transaction receipt would only reflect the transaction but no end or beginning balance.
This process was implemented on 10/14/2024 |
10/14/2024
| Implemented |
| 6400.67(a) | There was rust on the air intake in the individual's bathroom over 10% of the surface. | Floors, walls, ceilings and other surfaces shall be in good repair. | The residential manager is responsible for this correction
The agency shall ensure floors, walls, ceilings and other surfaces shall be in good repair.
On 09/28/24 the program manager engaged property maintenance to review all surfaces at the home and replace/repair any damages. |
10/14/2024
| Implemented |
| 6400.71 | There was a cordless phone without emergency numbers in the kitchen. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The Program Manager is responsible for this correction.
The agency shall ensure that Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
This violation was corrected on the day of the inspection. A laminated sheet with phone numbers was placed on the wall. Every home has a cordless phone and so the emergency numbers have been taped to the back of the handsets for ease of access |
10/15/2024
| Implemented |
| 6400.82(f) | There were no paper or cloth towels for use after handwashing in the bathroom | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The program manager is responsible for making this correction.
A paper towel dispenser plus paper towel would be installed in the bathroom
The dispenser has been installed. The installation date was 10/11/2024 |
10/11/2024
| Implemented |
| 6400.171 | The milk in the home had a "use by" date of September 13, 2024.
A container of bacon and salad mix was uncovered in the refrigerator. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The Program manager would be responsible for this item.
The agency shall ensure food shall be protected from contamination while being stored, prepared, transported and served.
On 09/25/24 the program manager directed that the milk be discarded immediately. The agency has also instituted additional measures to maintain compliance and protection of food. |
10/15/2024
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's most recent assessment does not clearly document Individual #1's progress in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Specialist is responsible to correct this violation
The assessment would include the individuals progress over that last 365 days and current level of financial independence.
The individual's assessment has been updated to correctly reflect the individual's financial progress over the last 365 days and current level. (see attachment) The correction was completed by the 14th of October 2024 |
10/14/2024
| Implemented |
| 6400.214(b) | A current copy of Individual #1's assessment was not available in the home on September 25, 2024 | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The Program Specialist is responsible to correct this violation
The agency shall ensure the most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
The individuals in home binder was immediately updated to include individuals most recent assessment. The correction was made 10/04/2024 |
10/04/2024
| Implemented |
| 6400.18(i) | Eight (8) incidents were reported relating to Individual #1 between June 25, 2024 and August 19, 2024. As of September 27, 2024, these incidents have not been finalized, nor has the Department been notified of the need for an extension. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | The QA manager is responsible to maintain this code
The agency would ensure the The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.
Between 09/27-2024 and 09/29/2024 the QA manager reviewed all open incidents. the QA further went ahead to re assign incidents where necessary. The QA manager additionally requested extensions for incidents that could not be immediately finalized. |
09/30/2024
| Implemented |
| 6400.24 | The home is subject to 55 Pa.Code Chapter 6100 (Relating to Services for Individuals with an Intellectual Disability or Autism). § 6100.687(a) provides: The provider shall ensure that a room and board residency agreement, on a form specified by the Department, is completed and signed by the individual annually.
Individual #1 does not have a room and board residency agreement. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | DPOC
The provider will again request that Individual #1, or their guardian sign the room and board agreement and should either decline, the provider will explain the importance of a completed contract and provide copies of all applicable regulations to them. Should the individual or guardian continue to decline to sign the form then the provider will issue a 45-day discharge notice/letter after following all the steps above then, the provider will explain that a 45-day discharge notice that follows all requirements under§ 6100.304 will be issued.
6100.304 Written notice:
(a) If the provider is no longer able or willing to provide a service for an individual in accordance with § 6100.303 (relating to involuntary transfer or change of provider), the provider shall provide written notice to the following at least 45 days prior to the date of the proposed change of provider or transfer to the individual, persons designated by the individual, the team, the AE, SCO and ODP and in accordance with all of the requirements in 6100.303 and 304. |
02/14/2025
| Not Implemented |
| 6400.163(h) | Acetaminophen was present in Individual #1's medication box that had expired on March 12, 2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Program specialist and medical director are responsible for ensuring compliance of this regulations.
On 9/25/2024 upon discovering, immediate action was taken
The program specialist immediately directed the program manager to remove Immediately remove the expired Acetaminophen from Individual #1's medication box and ensure that it is properly disposed of according to the agency¿s medication disposal policy.
The program manager also checked for Other Expired Medications in Individual #1's medication box and other individuals¿ medication boxes to ensure no other expired medications are present. |
09/25/2024
| Implemented |
| 6400.186 | Individual #1's June 27, 2024, ISP reads, "the blinds of the house shall be kept open". All Blinds in all the rooms were found closed when the Department arrived onsite. | The home shall implement the individual plan, including revisions. | The program specialist and program manager would be responsible for ensuring compliance and remediation
The agency shall implement the individual plan, including revisions.
The agency had a staff meeting with the individual's team on 10/04/2024 to mandate and ensure that all aspects of the ISP were followed. The training required a complete review of the ISP and a refresher of its main components. The training also communicated the ISP directive. |
10/04/2024
| Implemented |