| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At 12:05 PM on 6/12/24, there was no outside light or sufficient nearby lighting source found outside the kitchen side-door exit. [Repeated Violation-9/20/23, et al] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Solidarity Management contacted the Handyman on 6/12/2024 and a light bulb was installed outside the kitchen side-door exit on 6/13/2024. |
06/13/2024
| Implemented |
| 6400.67(a) | At 12:04 PM on 6/12/24, the three steps from the main level to the lower level were observed with frayed carpeting, as the fabric was tearing and separating at the seams where each tread and riser meet. [Repeated Violation-11/16/23, et al; 2/29/24, et al; 4/10/24, et al; & 5/14/24, et al] | Floors, walls, ceilings and other surfaces shall be in good repair. | Solidarity Management contacted the Handyman on 6/12/2024 and the frayed carpeting on the three steps from the main level to the lower level were repaired on 6/15/2024. |
06/12/2024
| Implemented |
| 6400.101 | At 11:57 AM on 6/12/24, the door to the right of the window in the tv/ lounge room located on the lower level was observed with a sliding chain lock, creating a blocked egress. [Repeated Violation-9/20/23, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The home Lead removed the sliding chain lock on 6/14/2024. |
06/14/2024
| Implemented |
| 6400.141(a) | Individual #1's date-of-admission is 4/3/23. They had a physical examination completed on 10/10/22, and then again on 2/15/24. [Repeated Violation-9/20/23, et al] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program Specialist prepared a digital log for tracking Individual #1¿s physical examination on 6/24/2024. All household leads have access to the log. |
06/24/2024
| Implemented |
| 6400.141(c)(14) | Individual #2's date-of-admission is 10/5/23. Their most recent physical examination completed on 8/2/23, did not include information pertinent to diagnosis and treatment in the case of an emergency. This field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 6/26/24, the medication administration trainer trained all house leads on how to complete the individual physical examination records to ensure the physical examination includes information pertinent to diagnosis and treatment in the case of an emergency. |
06/26/2024
| Implemented |
| 6400.181(d) | Individual #2's most recent assessment completed on 12/5/23, was not signed by the program specialist. | The program specialist shall sign and date the assessment. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to include signature and date of assessment. |
06/17/2024
| Not Implemented |
| 6400.181(e)(6) | Individual #2's most recent assessment completed on 12/5/23, did not address their ability to recognize and safely avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to include information about the individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. |
06/17/2024
| Not Implemented |
| 6400.181(e)(7) | Individual #2's most recent assessment completed on 12/5/23, did not address their ability to quickly move away from heat sources which exceed 120 degrees Fahrenheit and are not insulated. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to include information about the individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. |
06/17/2024
| Not Implemented |
| 6400.181(e)(10) | Individual #1's most recent assessment completed on 5/27/24, did not include a lifetime medical history. Individual #2's most recent assessment completed on 12/5/23, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The Program Specialist designed a new assessment template on 6/17/2024 to include a lifetime medical history of the individual. |
06/17/2024
| Not Implemented |
| 6400.181(e)(14) | Individual #2's most recent assessment completed on 12/5/23, did not address their knowledge of water safety. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to include information about the individual¿s knowledge of water safety and ability to swim. |
06/17/2024
| Not Implemented |
| 6400.18(a)(9) | Enterprise Incident Management Incident #9329365 for serious injury requiring treatment beyond first aid was discovered on 11/23/23 and reported on 12/13/23. [Repeated Violation-9/20/23, et al] | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Injury requiring treatment beyond first aid.
| A new Incident Manager, who is also a Certified Investigator (CI) was hired on 2/20/2024 to work with the in-house CI to ensure incidents are initiated and investigated timely. The Incident manager and in-house Certified Investigator organized a training on 6/18/2024 to discuss ODP Incident Management Bulletin # 00-21-02 with all staff to ensure that incidents are reported and investigated timely. Also, the incident management representative and in-house CI are working together to ensure investigations are initiated in a timely manner. |
06/18/2024
| Implemented |
| 6400.163(h) | At 11:40 PM on 6/12/24, the following discontinued and expired medications prescribed for Individual #1 were discovered in a bag located in the closet of the staff office: Trazodone 50 mg tablet that had been discontinued on 2/29/24; Hydroxyzine HCL 50 mg tablet that had been discontinued on 3/4/24; and Sodium Fluoride 5000 PM Paste that had expired on 6/3/24. [Repeated Violation-4/10/24, et al] | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The discontinued and expired medications prescribed for Individual #1 were removed from the locked room and destroyed on 6/12/2024 in accordance with Solidarity¿s Medication Disposal Policy. |
06/12/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. Medication review completed 12/1/23 and 5/22/24 did not include the specific medications, dosages, and reasons for prescribing. The reviews completed 1/11/24 and 2/9/24 did not include the reasons for prescribing the medications. Medication reviews were completed 2/9/2 and then again 5/22/24. Individual #2 is prescribed medication to treat symptoms of a psychiatric illness. Reviews completed 11/16/23 and 12/18/23 did not include the specific medications reviewed. medication reviews were completed on 12/18/23 and then again 4/17/24. [Repeated Violation-9/20/23, et al] | 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. | The Program Specialist designed a Psychiatric Medication review template on June 19, 2024, ensuring the review every 3 months by a licensed physician documents the reason for prescribing the medication, the need to continue the medication and the necessary dosage. |
06/19/2024
| Implemented |
| 6400.181(f) | Individual #1's assessment completed on 6/1/23 was not provided to the plan team for the meeting held on 8/3/23. Individual #2's assessment completed on 12/5/23 and sent to the plan team on 2/11/24 for an individual support plan annual review meeting that had already been held on 1/18/24. [Repeated Violation-9/20/23, et al] | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to comply with Pa 6400.181 and ensure that the date the assessment is provided to the individual plan team members is at least 30 calendar days prior to an individual plan meeting. |
06/17/2024
| Implemented |
| 6400.182(c) | Individual #2's most recent assessment completed on 12/5/23, indicates they are independent in fire evacuation. However, Individual #2's individual plan last updated on 6/5/24, informs that they require supervision to evacuate safely in the event of a fire. Regarding poison safety, Individual #2's 12/5/23 assessment explains they are able to recognize poisonous substances and no supervision is required. In contrast, their individual plan last updated on 6/5/24, states they need supervised around poisons and such substances are made inaccessible. Lastly, for the safety domain involving dangerous heat sources, Individual #2's 12/5/23 assessment indicates they are unable to regulate their own water but are aware of dangerous heat sources. However, their individual plan last updated on 6/5/24, explains only that Individual #2, "will turn the water temperature up all the way to hot and make [their] skin red," and leaves other dangerous heat sources unaddressed. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to comply with Pa 6400.181 and is currently completing the assessments of individuals to ensure consistency with the individual support plan. |
06/17/2024
| Implemented |