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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(b) | Direct Service Worker #1 participated in training to encompass general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department on 5/30/2023 and again on 6/27/2024. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | On 3/20/25, the Vice President of Organizational Strategy and Integrity retrained the Career Development Manager on regulation 6400.46(b). |
03/20/2025
| Implemented |
| 6400.165(d) | On 3/12/2025 at approximately 9:30am, the following pro re nata medications prescribed to Individual #1 were labeled as "House Stock Medications": Antacid Sus Antigas 15mL, Loperamide Liq 1mg/7.5mL, Loratadine Tab 10mg, Geri-Tussin Liq 100/5mL, Milk of Magn Sus 1200/15, and Fleet Enema. The house stock prescription medications were to be utilized by any individual in the home with a current order for said medication. Additionally, the pharmacy issued medication label did not include administration instructions such as the individual's name, medication dosage, administration route, or frequency of administration. | A prescription medication shall be used only by the individual for whom the prescription was prescribed. | On 3/13/25, the Vice President of Residential and Disability Services retrained the Nurses on regulation 6400.165(d). Medication labels will be completed by 5/16/25. |
05/16/2025
| Implemented |
| 6400.207(5)(III) | On 3/12/2025 at 10:04am, Individual #1's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for full bed rails with no padding on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, the most current assessment dated 10/1/2024 does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #1's individual plan last updated 3/5/2025 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 9:59am, Individual #2's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for full side rails with hospital bed on 3/12/2025, after the violation was identified by the licensing representative. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's individual plan last updated 3/11/2025 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 10:06am, Individual #3's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for full bed rails with no padding on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #3's individual plan last updated 3/12/2025 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 10:06am, Individual #4's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for full bed rails with no padding on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #4's individual plan last updated 11/13/2024 does not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | On 3/25/25, the Vice President of Residential and Disability Services retrained the Program Specialists to include documentation of regulation 6400.207(5)(iii) in the annual assessment, along with a physician's order. |
03/25/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | The "Rights" forms, signed by the court appointed guardian for Individual #1 on 11/15/14, and Individual #2 on 3/19/14, did not state the full rights per regulation 33(e) regarding privacy and regulation 33(j) regarding voting.
Per 6400.33(e), "An individual has the right to privacy in bedrooms, bathrooms and during personal care." Individual #1 and Individual #2's signed statements include "Each individual will be given privacy during treatment and care of personal needs."
Per 6400.33(j), "An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections." Individual #1 and Individual #2's signed statement does not include this statement.
| Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The Quality Assurance Director revised the Client Rights to include "each individual has the right to privacy in bedrooms, bathrooms, and during personal care" and "each individual who is of voting age has the right to vote and will be assisted to register and vote in the elections." The Program Specialist will have Client #1 and #2 and/or Parent/Guardian sign the revised rights by January 6, 2015. The Administrative Assistance will send the revised Client Rights to all clients and/or parent guardian by January 15, 2015. The Program Specialist will ensure the Client Rights are reviewed and the acknowledgement Form is signed by the client and/or parent/guardian annually and filed in the client's Program Book. |
12/29/2014
| Implemented |
| 6400.103 | The written emergency evacuation procedure does not include the means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Quality Assurance Director revised the Emergency Evacuation Plan on 12/24/14 to include that the means of transportation will be by Agency and Staff vehicles and that the emergency shelter location are the Avalon Hotel on 16 West 10th Street, Erie, PA 16501, client family member's, or staff member's homes. The revised Emergency Evacuation Plan will be distributed to all group homes by january 1, 2015. |
12/29/2014
| Implemented |
| 6400.106 | The furnace has not been inspected and cleaned for several years by a professional furnace cleaning company or trained staff person. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Maintenance Manager will schedule the furnace cleaning and inspection with a professional cleaning company by January 16, 2015. The Maintenance Manager will schedule the cleaning and inspections to be done by a professional cleaning company annually. The Program Specialist will receive a copy of the cleaning and inspection reports to ensure they were done by the professionally cleaning company annually. |
12/29/2014
| Implemented |
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