| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not completed a self-assessment, within 3 to 6 months prior to the expiration of their license. Their license expiration date is 3/5/22; the self-assessment provided was completed on 3/7/22. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Agency has hired a compliance specialist that will oversee quarterly self-assessments of licensed homes and record compliance with this chapter. |
| Implemented |
| 6400.22(a) | No policy was provided to licensing for expenditures made on behalf on the individuals. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | The Agency has disbursed a check to the Individual refunding the total amount of $1,317.41 and submitted applications to third party payee companies (Advocacy Alliance and ARC Alliance) to be representative payees for Individuals served. |
05/31/2022
| Implemented |
| 6400.22(c) | On the following dates it was determined by the agency's record that Individual 1 was charged for the following items:
12/2/21-Food items from Instacart totaling 337.39 with 44.29 in fees for taxes, delivery, heavy item delivery and services fees.
12/22/21-Amazon purchases in the form of whole sets of bowls, plates and flatware. 17-piece bathroom set. A cordless phone. Toilet paper.
1/3/22-25 grocery items totaling 174.64 and another 14.59 in fees.
1/13/22- 33 grocery items totaling 210.00 and another 22.00 in fees for taxes, delivery, heavy item delivery and services fees. The receipt for this one shows a totaling mistake where the total of items with the fees does not seem to add up to the amount which was charged.
1/7/22, - a charge of 39.82 2/3/22 for 39.96, 2/3/22 for 134.00 from Amazon was made for depends under garments. There are many purchase dates for this item which needs to be in the record of the individual along with a medical necessity order and should be put through the insurance.
1/17/22- An Amazon purchase was made for the following items: Pill cutters totaling 7.41, frying pan set totaling 31.79 (also a pan set was purchased at Walmart on 12/22/21 for 39.97), slow cooker totaling 20.68, paper towels and depends (still needing the above stated items) totaling 156.05, and tide pods totaling 45.00. | Individual funds and property shall be used for the individual's benefit. | The Agency has disbursed a check to the Individual refunding the total amount of $1,317.41 and submitted applications to third party payee companies (Advocacy Alliance and ARC Alliance) to be representative payees for Individuals served. |
05/31/2022
| Implemented |
| 6400.22(d)(2) | There is no clear record or ledger of actual purchases aside from receipts that show which items were purchased on what dates. A separate ledger should be kept showing all purchases in order of the dates that items were purchased along with an explanation of the necessity for that purchase. | (2) Disbursements made to or for the individual.
| The Agency has disbursed a check to the Individual refunding the total amount of $1,317.41 and submitted applications to third party payee companies (Advocacy Alliance and ARC Alliance) to be representative payees for Individuals served. |
05/31/2022
| Implemented |
| 6400.22(f) | On the following dates it was determined by the agency's record that Individual 1 was charged for the following items:
12/2/21-Food items from Instacart totaling 337.39 with 44.29 in fees for taxes, delivery, heavy item delivery and services fees.
12/22/21-Amazon purchases in the form of whole sets of bowls, plates and flatware. 17-piece bathroom set. A cordless phone. Toilet paper.
1/3/22-25 grocery items totaling 174.64 and another 14.59 in fees.
1/13/22- 33 grocery items totaling 210.00 and another 22.00 in fees for taxes, delivery, heavy item delivery and services fees. The receipt for this one shows a totaling mistake where the total of items with the fees does not seem to add up to the amount which was charged.
1/7/22, - a charge of 39.82 2/3/22 for 39.96, 2/3/22 for 134.00 from Amazon was made for depends under garments. There are many purchase dates for this item which needs to be in the record of the individual along with a medical necessity order and should be put through the insurance.
1/17/22- An Amazon purchase was made for the following items: Pill cutters totaling 7.41, frying pan set totaling 31.79 (also a pan set was purchased at Walmart on 12/22/21 for 39.97), slow cooker totaling 20.68, paper towels and depends (still needing the above stated items) totaling 156.05, and tide pods totaling 45.00. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | The Agency has disbursed a check to the Individual refunding the total amount of $1,317.41 and submitted applications to third party payee companies (Advocacy Alliance and ARC Alliance) to be representative payees for Individuals served. |
05/31/2022
| Implemented |
| 6400.110(c) | The smoke detector located in the hall common area did not function. Batteries were replaced upon discovery of the non functioning alarm by the agency. (The bedroom smoke detectors functioned so it was not an immediate safety risk). | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | Smoke detector has been placed in the common area of the home. |
05/31/2022
| Implemented |
| 6400.141(c)(6) | Individual 1's physical dated 9/23/21 made mention of a TB test but no laboratory information or results were included. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual 1¿s physical dated 09/23/2021 has been updated with laboratory information that include Tuberculin skin testing by Mantoux method with negative results attached. |
04/27/2022
| Implemented |
| 6400.141(c)(14) | Individual 1's annual physical dated 9/23/21 did not include information pertinent to diagnosis in case of an emergency. The area on the form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Individual physical has been updated to include medical information pertinent to diagnosis and treatment in case of an emergency. |
04/27/2022
| Implemented |
| 6400.144 | The March glucose log for individual 1 was not completed during site review. The medication record notated the sugar readings were read but the separate log notating protocol and sugar readings was left blank. The measuring device did measure accurately the sugar when used. The device was missing some readings, March 11, 2022 only had one date and time with no explanation notated on the log for the missed stored number reading. Individual 1 is also wearing various adult undergarments for incontinence, but the record does not indicate if there is a medical order in existence. A medical order dated 3/17/22 was submitted during the inspection. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Medical order was received for the individual participant to use adult undergarment for incontinence. scheduled to receive first delivery on 04/27/2022. |
04/27/2022
| Implemented |
| 6400.181(e)(13)(i) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The Individuals assessment has been updated to reflect the individual¿s progress over the last 365 calendar days and current level in the following areas: Health. |
05/04/2022
| Implemented |
| 6400.181(e)(13)(ii) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Individuals assessment has been updated to reflect the individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. |
05/06/2022
| Implemented |
| 6400.181(e)(13)(iii) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The Individuals assessment has been updated to reflect the individual¿s progress over the last 365 calendar days and current level in the following areas: Activities of residential living. |
05/06/2022
| Implemented |
| 6400.181(e)(13)(iv) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The Individuals assessment has been updated to reflect the individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. |
05/06/2022
| Implemented |
| 6400.181(e)(13)(v) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The Individuals assessment has been updated to reflect the individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. |
05/06/2022
| Implemented |
| 6400.181(e)(13)(vi) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The Individuals assessment has been updated to reflect the individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. |
05/06/2022
| Implemented |
| 6400.181(e)(13)(vii) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | 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 Individuals assessment has been updated to reflect the individual¿s progress over the last 365 calendar days and current level in the following areas: Financial independence. |
05/06/2022
| Implemented |
| 6400.181(e)(13)(viii) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Managing personal property. |
05/06/2022
| Implemented |
| 6400.181(e)(13)(ix) | Individual 1's annual assessment dated 8/19/2021 does not reference progress and growth in each of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. |
05/06/2022
| Implemented |
| 6400.214(a) | Individual 1's record did not contain a place where eye color, weight and identifying marks were recorded. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | Individual face sheet has been developed that indicates eye color, weight, identifying marks and all required in § 6400.213(1) (relating to content of records) |
05/06/2022
| Implemented |
| 6400.217 | Individual 1's record did not contain a signed consent of information to be released. Attempts were made to the parent, but it is unclear if the parent has court appointed guardianship. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Individual SC has been informed to witness the signing of the Individuals annual consent in absence of his parents. Virtual meeting options have also been recommended.5/10/2022 |
05/10/2022
| Implemented |
| 6400.31(b) | Individual 1's record did not contain a signed copy of rights. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Individual SC has been informed to witness the signing of the Individuals annual consent in absence of his parents. Signed consents shall include Copy of Individuals rights. |
05/10/2022
| Implemented |
| 6400.46(d) | Staff Member 1's 11/29/20 CPR training did not have an in-person classroom component. Staff Member 2 did not receive CPR/first aid training, as documentation was not provided. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | CPR/First Aid training has been scheduled for May 25th 2022 for all staff providing services. |
05/25/2022
| Implemented |
| 6400.51(b)(1) | Staff Member 2's orientation did not covere the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, as documentation was not provided. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff member #2 has completed training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. |
04/27/2022
| Implemented |
| 6400.51(b)(2) | Staff Member 2's orientation did not covere the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, as documentation was not provided. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Staff #2 has completed training in The prevention, detection and reporting of abuse,
suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S.
§§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective
Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. |
05/25/2022
| Implemented |
| 6400.51(b)(3) | Staff Member 2's orientation did not cover individual rights, as documentation was not provided. | The orientation must encompass the following areas: Individual rights. | Staff member #2 has completed training in the Area of Individual rights. |
04/27/2022
| Implemented |
| 6400.51(b)(4) | Staff Member 2's orientation did not cover recognizing and reporting incidents, as documentation was not provided. | The orientation must encompass the following areas: recognizing and reporting incidents. | Staff member #2 has completed training in the Area of recognizing and reporting incidents. |
04/27/2022
| Implemented |
| 6400.52(c)(1) | Staff Member 1 and the CEO's 2021 annual trainings did not cover the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, as documentation was not provided. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff Member 1 and the CEO have completed training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. |
04/27/2022
| Implemented |
| 6400.52(c)(2) | Staff Member 1 and the CEO's 2021 annual trainings did not cover the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, as documentation was not provided. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff Member 1 and the CEO have completed training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. |
04/27/2022
| Implemented |
| 6400.52(c)(3) | Staff Member 1 and the CEO's 2021 annual trainings did not cover individual rights, as documentation was not provided. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff Member 1 and the CEO have completed annual trainings the following areas: Individual rights. |
04/27/2022
| Implemented |
| 6400.52(c)(4) | Staff Member 1 and the CEO's 2021 annual trainings did not cover recognizing and reporting incidents, as documentation was not provided. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff Member 1 and the CEO have completed annual trainings the following areas: Recognizing and reporting incidents. |
04/27/2022
| Implemented |