| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff 1's paperwork indicated that they lived outside of Pennsylvania within 2 years of hire; however, an FBI check was not on file. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| FBI background check has yet to be completed by employee attending police station for fingerprints. Still waiting for employee to complete this as she is not a full-time member of staff and has been out of the country for long periods of time since her official start date.
Staff member will not be offered any further shifts until FBI background check is complete from 08/13/2025 |
08/13/2025
| Implemented |
| 6400.142(f) | A Dental Hygiene Plan was not in place for Individual 1. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | ISP for Individual 1 only states that they require reminding to brush teeth. They are independent with the process of brushing and cleaning their teeth.
ISP review is an inter disciplinary process and it has not been previously noted that the individual requires a separate plan relating to dental hygiene independence.
Dentist visit records do not indicate that any intervention is required from the provider relating to the individual managing their own dental hygiene. |
07/09/2025
| Implemented |
| 6400.143(a) | Individual 1 has refused to complete a gynecological examination and Pap test (currently and prior to admission) and there is no documentation in the individual's record to show they have been trained about the health benefits of these exams. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual 1 attended OB/GYN appointment on 07/22/2025 and successfully completed both mammogram and GYN exam with no abnormal findings and no follow up recommendations.
Staff will continue to educate and inform female individuals in our program of the importance of attending OB/GYN appointments from a wellness perspective.
Prior refusal was documented in individuals record but was not a pattern of repeated refusal. |
07/22/2025
| Implemented |
| 6400.145(1) | An Emergency Medical Plan was not in place for Individual 1. | 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. | Emergency Medical Plans are covered in an overarching policy/procedure entitled `Crisis Procedure¿ that applies to all individuals
This clearly outlines the source of emergency healthcare for individuals based on their geographic location as follows:
-All Individuals residing at our Westside Home will utilize the Phoenixville Hospital.
-All individuals residing at our Indigo Home will utilize the Paoli Hospital.
-All Individuals residing at our Westfield/Cyprus Homes will utilize the Pottstown Tower Health. |
07/09/2025
| Implemented |
| 6400.181(a) | Individual 1 was admitted on 08/13/2024, and the initial Individual Assessment was completed on 11/13/2024; exceeding the 60 calendar day requirement. | 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. | Violation is historical and related to elapsed time frame rather than absence of required document.
Individual Assessment was completed, just not within required time frame.
Program Specialist spoken to around specific circumstances as to why IA was late for this individual ¿ misunderstanding around timeframes, believed it was 90 days from admission. |
11/13/2024
| Implemented |