Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(3) | The 06/05/24 physical examination for individual 3 does not discuss immunizations and neither do any of his previous physical exams in the file. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | On July 19, 2024, our Residential Manager communicated with individual #3's PCP to begin administering and updating the individual¿s immunization records. Both the Program Specialist and Residential Manager are responsible for ensuring that the individual¿s immunization records are accurate and that all information relevant to maintaining the individual¿s annual physical is in compliance with 55 PA Code Chapter 6400.141(c)(3). Additionally, we have reviewed all resident records to identify any others that may be out of compliance and require correction. |
07/28/2024
| Implemented |
6400.32(e) | The individual Rights statement provided to individual 3 does not include that an individual has the right to make choices and accept risks. | An individual has the right to make choices and accept risks. | On July 19, 2024, the Program Specialist, under the supervision of the Lifetime Q&R Representative, updated the individual's rights to include the previously missing statement: "The individual has the right to make choices and accept risks." Additionally, we have reviewed all resident records to identify any others that may be out of compliance and require correction. |
07/28/2024
| Implemented |
6400.32(f) | The individual Rights statement provided to individual 3 does not include that an individual has the right to refuse to participate in activities and services. | An individual has the right to refuse to participate in activities and services. | On July 19, 2024, the Program Specialist, under the supervision of the Lifetime Q&R Representative, updated the individual's rights to include the previously missing statement: "right to refuse to participate in activities and services individual has the right to refuse to participate in activities and services.." Additionally, we have reviewed all resident records to identify any others that may be out of compliance and require correction.
Moving forward, the Program Specialist and the Q&R Representative will conduct bi-annual self-audits of all individual consent packages containing the Individual Rights Statement to ensure compliance with 55 PA Code Chapter 6400.32(f). This process will be overseen by our Q&R Representative. |
07/28/2024
| Implemented |
6400.32(p) | The individual Rights statement provided to individual 3 does not include that an individual has the right to choose persons with whom to share a bedroom. | An individual has the right to choose persons with whom to share a bedroom. | On July 19, 2024, the Program Specialist, under the supervision of the Lifetime Q&R Representative, updated the individual's rights to include the previously missing statement: "An individual has the right to choose persons with whom to share a bedroom." Additionally, we have reviewed all resident records to identify any others that may be out of compliance and require correction. |
07/28/2024
| Implemented |
6400.32(q) | The individual Rights statement provided to individual 3 does not include that an individual has the right to furnish and decorate the individual's bedroom and the common areas of the home. | An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices). | On July 19, 2024, the Program Specialist, under the supervision of the Lifetime Q&R Representative, updated the individual's rights to include the previously missing statement: "An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home by § 6400.33 (relating to the negotiation of choices).-." Additionally, we have reviewed all resident records to identify any others that may be out of compliance and require correction. |
07/28/2024
| Implemented |
6400.32(t) | The individual Rights statement provided to individual 3 does not include that an individual has the right to access food at any time. | An individual has the right to access food at any time. | On July 19, 2024, the Program Specialist, under the supervision of the Lifetime Q&R Representative, updated the individual's rights to include the previously missing statement: "An individual has the right to access food at any time.).-." Additionally, we have reviewed all resident records to identify any others that may be out of compliance and require correction. |
07/28/2024
| Implemented |
6400.165(g) | A psychiatric medication review was done for individual 3 on 03/19/24 and was not done again until 07/09/24. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Upon discovering the late psychotropic medication reviews for Individual #3, Lifetime Skills has implemented a policy to safeguard the health and safety of all individuals and rectify this violation. This policy ensures that all individuals prescribed psychotropic medications undergo quarterly medication reviews, with documentation in their medical binders. |
07/28/2024
| Implemented |