| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(3) | Individual #2, date of admission 7/11/2024, had a pre-admission physical examination completed on 4/23/2024. Individual #2's pre-admission physical examination did not include the individual's immunizations as recommended by the United States Public Health Service, Centers for Disease Control. Individual #2 also had a physical examination form completed by the primary care physician on 8/6/2024 which indicated that the individual's most current DT vaccination was completed on 6/14/2014.
Individual #3, date of admission 3/24/2024, had a pre-admission physical examination completed on 2/28/2024. Individual #3's pre-admission physical examination did not include the individual's immunizations as recommended by the United States Public Health Service, Centers for Disease Control. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #2 had her Immunization Tetanus and Diphtheria updated on _____add date_______. Individual #2 Physical form has been updated with the completed immunizations and filed in her records.
Individual #3 had his Immunization of Tetanus and Diphtheria updates on __Add date__________. Individual #3 Physical form has been updated with the completed immunizations and filed with his records. |
11/06/2024
| Implemented |
| 2380.111(c)(4) | Individual #1's annual physical examination, completed 2/19/2024, did not include vision and hearing screenings. These evaluation items were left blank on the physical examination form. No documentation of further evaluations by vison and hearing specialists could be provided.
Individual #2, date of admission 7/11/2024, had a pre-admission physical examination completed on 4/23/2024. Individual #2's pre-admission physical examination did not include vision and hearing screenings. These areas of assessment were not included on the physical examination form.
Individual #3, date of admission 3/24/2024, had a pre-admission physical examination completed on 2/28/2024. Individual #3's pre-admission physical examination did not include vision and hearing screenings. These areas of assessment were not included on the physical examination form.
Individual #4's annual physical examination, completed 2/19/2024, did not include vision and hearing screenings. These evaluation items were marked 'not assessed' on the physical examination form. No documentation of further evaluations by vison and hearing specialists could be provided. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Individual #1 letter was sent to her residential nurse requesting the assessment to include the vision and hearing evaluation. Date of letter sent 11-5-2024. Records for individual #1 will be updated upon obtaining current information.
Individual #2 letter sent to her family requesting the assessment to include the vision and hearing evaluation. Date of letter sent 11-5-2024. Records for individual #2 will be updated upon obtaining current information.
Individual #3 letter sent to his residential nurse requesting the assessment to include the vision and hearing evaluation. Date of letter sent 11-5-2024. Records for individual #3 will be updated upon obtaining current information.
Individual #4 letter sent to his family requesting the assessment to include the vision and hearing evaluation. Date of letter sent 11-5-2024. Records for Individual #4 will be updated with current information. |
11/06/2024
| Implemented |
| 2380.111(c)(6) | Individual #2, date of admission 7/11/2024, had a pre-admission physical examination completed on 4/23/2024. Individual #2's pre-admission physical examination did not include specific precautions that shall be taken if the individual has a serious communicable disease. This area of assessment was not included on the physical examination form.
Individual #3, date of admission 3/24/2024, had a pre-admission physical examination completed on 2/28/2024. Individual #3's pre-admission physical examination did not include specific precautions that shall be taken if the individual has a serious communicable disease. This area of assessment was not included on the physical examination form. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | Individual #2 has an updated Agency physical form with exam date of 4/23/2024 and signed by the physician on 8/6/2024, to include a completed communicable disease statement. The statement indicated that individual #2 is Free of Communicable Diseases.
Individual #3 has an updated Agency physical form with exam date of 3/10/2024 and signed by the physician on 3/29/2024. The statement indicated that Individuals #2 is Free of Communicable Diseases. |
11/06/2024
| Implemented |
| 2380.111(c)(9) | Individual #2, date of admission 7/11/2024, had a pre-admission physical examination completed on 4/23/2024. Individual #2's pre-admission physical examination did not include the individual's allergies or contraindicated medications. This area of assessment was not included on the physical examination form. According to Individual #2's support plan, last updated 10/21/2024, they have a severe peanut allergy and require the use of an Epi-Pen if consumed.
Individual #3, date of admission 3/24/2024, had a pre-admission physical examination completed on 2/28/2024. Individual #3's pre-admission physical examination did not include the individual's allergies or contraindicated medications. This area of assessment was not included on the physical examination form. | The physical examination shall include: Allergies or contraindicated medication. | Individual #2 has an updated Agency physical form with exam date of 4/23/2024 and signed by the physician on 8/6/2024, to include the allergies and contraindicated medications.
Individual #3 has an updated Agency physical form with exam date of 3/10/2024 and signed by the physician on 3/29/2024, to include the allergies and contraindicated medications. |
11/06/2024
| Implemented |
| 2380.173(1)(ii) | Individual #1's record did not include the individual's eye color. This information was left blank on the individual's data sheet and could not be located anywhere else in the individual's record. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | Individual #1 Personal Data Information sheet has been updated to include eye color and checked for all other requirements per the regulation on 11-4-2024. |
11/06/2024
| Implemented |
| 2380.173(1)(iv) | Individual #1's record did not include the individual's religious preferences. This information was documented as not applicable on the individual's data sheet and could not be located anywhere else in the individual's record. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Individual #1 Personal Data Information sheet has been updated to include Religious Preference and all other information checked for accuracy per the regulation on 11-4-2024 |
11/06/2024
| Implemented |
| 2380.181(a) | Individual #2, date of admission 7/11/2024, had an initial assessment completed on 9/9/2024. This assessment indicated that Individual #2 requires partial physical assistance to evacuate in the case of a fire. Individual #2's support plan, last updated 10/21/2024, indicates that the individual can evacuate independently. According to interviews with agency staff, Individual #2 has demonstrated that they are able to evacuate independently; however, the individual's assessment has not been updated to accurately reflect this change in need. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individual #2 Agency assessment was sent to the Supports Coordinator on 10/30/2024 to include the updated information. A follow up email was sent on 11/5/2024 to ensure all elements of the missing information in the ISP that were identified in the assessment would be added to the ISP. |
11/06/2024
| Implemented |
| 2380.181(e)(6) | Individual #1's assessment, completed 10/13/2023, did not include an assessment of the individual's ability to safely use or avoid poisonous substances when in the presence of poisonous materials. In regard to poison safety, the individual's assessment stated, "[Individual #1]'s safety is protected by the [agency] staff. All poisonous materials are kept locked on-site."
Individual #2's assessment, completed 9/9/2024, did not include an assessment of the individual's ability to safely use or avoid poisonous substances when in the presence of poisonous materials. In regard to poison safety, the individual's assessment stated, "Poisons should be kept out of reach."
Individual #3's assessment, completed 5/2/2024, did not include an assessment of the individual's ability to safely use or avoid poisonous substances when in the presence of poisonous materials. In regard to poison safety, the individual's assessment stated, "[Individual #3] does have some safety skills, but it is questionable if [the individual] would be safe around poisons."
Individual #4's assessment, completed 6/21/2024, did not include an assessment of the individual's ability to safely use or avoid poisonous substances when in the presence of poisonous materials. In regard to poison safety, the individual's assessment stated, "Poisons, chemicals, and cleaners are locked up on site. It is unknown of [Individual #4]'s awareness of poisonous materials, but it has been observed that [Individual #4] does not seek out these items." | 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. | Individual #1 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their awareness relating to poisonous materials. The updated assessment will be sent to the Supports Coordinator to include the updated information in the ISP. A follow up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding awareness of poisonous materials is added to the ISP.
Individual #2 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their awareness relating to poisonous materials. The updated assessment will be sent to the Supports Coordinator to include the updated information in the ISP. A follow up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding awareness of poisonous materials is added to the ISP.
Individual #3 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their awareness relating to poisonous materials. The updated assessment will be sent to the Supports Coordinator to include the updated information in the ISP. A follow up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding awareness of poisonous materials is added to the ISP.
Individual #4 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their awareness relating to poisonous materials. The updated assessment will be sent to the Supports Coordinator to include the updated information in the ISP. A follow up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding awareness of poisonous materials is added to the ISP. |
11/06/2024
| Implemented |
| 2380.181(e)(7) | Individual #1's assessment, completed 10/13/2023, did not include an assessment of 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. In regard to the individual's safety around heat sources, the individual's assessment stated, "[Individual #1]'s safety is protected by the [agency] staff."
Individual #3's assessment, completed 5/2/2024, did not include an assessment of 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. In regard to the individual's safety around heat sources, the individual's assessment stated, "[Individual #3] does have some safety skills, but it is questionable if [the individual] would be careful around some heat sources."
Individual #4's assessment, completed 6/21/2024, did not include an assessment of 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. In regard to Individual #4's safety around heat sources, the individual's assessment stated, "Awareness in this area is unknown. Will determine [Individual #4]'s awareness of all heating sources." | 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. | Individual #1 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources. The updated assessment will be sent to the Supports Coordinator to include the updated information. A follow-up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding their knowledge of heat sources is added to the ISP.
Individual #2 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources. The updated assessment will be sent to the Supports Coordinator to include the updated information. A follow-up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding their knowledge of heat sources is added to the ISP.
Individual #3 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources. The updated assessment will be sent to the Supports Coordinator to include the updated information. A follow-up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding their knowledge of heat sources is added to the ISP.
Individual #4 Agency assessment was updated on 11/6/2024 to include an accurate assessment of their knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources. The updated assessment will be sent to the Supports Coordinator to include the updated information. A follow-up email will be sent to the Supports Coordinator after one week if needed to ensure that the information regarding their knowledge of heat sources is added to the ISP. |
11/06/2024
| Implemented |