| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | Individual 1 right bedroom window is missing a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Individual 1 right bedroom window is missing a screen. The screen on the individual window got loose and fell off. On August 4, 2023, the CEO and the agency's maintenance team successfully installed a new screen in the window of the bedroom assigned to Individual #1. |
08/04/2023
| Implemented |
| 6400.112(c) | The fire drill record had no start and end time listed for 1/30/23. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The fire drill record had no start and end time.
8/4/2023, Lifetime Skills through the CEO has revised its fire drill record form, ensuring that all home fire drill records now include both start and end times for each fire drill conducted. |
08/04/2023
| Implemented |
| 6400.141(a) | The individual's File only contains the current physical dated 7/6/23. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The individual's File only contains the current physical. The individual was admitted to Lifetime Skills CLA from a hotel and was in an emergency for placement.
Lifetime Skills Program Specialist has taken action to address this violation of 55 PA Code Chapter 6400.141(a), which mandates that individuals must undergo a physical examination within 12 months prior to admission and annually thereafter. |
08/04/2023
| Implemented |
| 6400.141(c)(4) | Individual 1's record recommended yearly vision screening, but no vision screening is in the binder. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual 1's record recommended yearly vision screening, but no vision screening is in the binder. On October 2, 2023, the program specialist updated vision records and ensured that all individuals received annual vision screenings. |
10/02/2023
| Implemented |
| 6400.141(c)(7) | Individual 1's binder did not contain any genealogical exam at all. Her binder only contained a non-sophisticated visit to her primary care physician in 2022 where a culture was performed and a gyno visit was recommended asap as a result.
No gyno exam for individual . Just an md visit where a culture was done in 2022. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual 1's binder did not contain any genealogical exam. On October 2, 2023, the program specialist and house manager ensured that Individual 1 completed her gyno exam. |
10/02/2023
| Implemented |
| 6400.141(c)(14) | Medical info pertinent to diagnosis was left blank on individual 1's physical dated 7/7/23. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Medical information was left blank. On August 2, 2023, the program specialist was assigned the responsibility of updating the individual's physical examination record, ensuring that all information relevant to diagnosis and other sections is appropriately documented. |
10/28/2023
| Implemented |
| 6400.142(a) | Individual 1' s file did not contain annual dental exam nor plan.
None in binder. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | On 9/12/2023, the program specialist successfully completed and updated the annual dental examination record and dental plan for Individual #1. This was carried out with the primary objective of maintaining comprehensive documentation pertaining to the dental examination.
Attachment#7 |
09/12/2023
| Implemented |
| 6400.144 | Individual 1 medication kit is missing her albuterol AER HFA inhaler; per agency staff, they did not have an inhaler on them, either, while out in the community during the inspection. They were also missing their fluticasone 50 mcg. nasal spray medication; this is a regular medication, not PRN, and was not signed for at all during the month of July on the MAR. Their kit contained a prescription PRN Tylenol medication blister pack that was missing medication, but was not listed or tracked on their MAR. | 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.
| The Individual `1 medication kit is missing her albuterol inhaler, this violation occurred because the medication was discontinued. Lifetime Skills' house manager and administrator had made the needed changes and corrected on the Individual MAR. |
10/28/2023
| Implemented |
| 6400.181(a) | Annual compliance for the annual assessment within individual 1's binder could not be determined. The binder only contains the current year's assessment dated 4/15/23. | 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. | Individual 1¿s annual assessment 4/15/2023, however, it was not in the binder, the Lifetime Skills program specialist, in collaboration with the residential team, finalized the completion of the annual assessment for Individual #1 and securely filed both previous and current copies in Individual #1's binder. |
04/15/2023
| Implemented |
| 6400.181(d) | The annual assessment within individual 1 binder was not signed by the Program Specialist; the signature lines were left blank. | The program specialist shall sign and date the assessment. | The annual assessment within individual 1 binder was not signed by the Program Specialist On July 30, 2023, the Lifetime Skills program specialist signed all parts of the annual assessment for Individual #1 and ensured that copies were placed in Individual #1's binder. |
10/28/2023
| Implemented |
| 6400.18(i) | 6 open incidents beyond 30 days with no approved extension for individual 1 | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | Lifetime Skills' IM representative will take the necessary steps to request an extension when required for all incidents before completing the final sections. |
10/28/2023
| Implemented |
| 6400.34(a) | Individual 1 List of rights needs to be updated adding most recent two as well. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Lifetime skills via its program specialist has updated the individual rights to reflects new changes per the 6400 regulations. Updated copy of the individual rights is signed and placed in the individual binder. |
10/28/2023
| Implemented |
| 6400.165(g) | Individual 1 is prescribed psychotropic medications, but individual 1's binder was absent of any medication reviews. | 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. | Upon the discovery of Individual #1's missing psychotropic medication reviews, Lifetime Skills has implemented a policy to safeguard the health and safety of all individuals and rectify this violation. This policy ensures that all individuals who are prescribed psychotropic medications undergo quarterly medication reviews, and the documentation for these reviews is maintained in their respective medical binders. |
10/28/2023
| Implemented |
| 6400.181(f) | The annual assessment was provided within individual 1's binder. However, the 30day letter that needs to accompany it, informing support team 30 days prior, was not included. | 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 Program Specialist is assigned the responsibility of ensuring compliance with 55 PA Code Chapter 6400.181(f). In response to the violation, the following actions were taken: the Program Specialist prepared a 30-day letter to accompany the annual assessment for Individual 1's support team member (Support Coordinator), as well as for all other individuals. |
10/28/2023
| Implemented |