| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(c) | Program specialist Staff #1 shall have credentials and qualifications, which was not provided at inspection. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability. | Commonwealth Supportive Services Program Specialist has been working for this agency since 4/17/2017. She obtained her Masters Degree from the University of Gloucestershire in Cheltenham, England, and has been working with IDD for over six years. She has met the criteria of this position. Please see Staff # 1 credentials attached for your review. |
11/09/2022
| Implemented |
| 6400.65 | The window located in the bathroom was not operable and would not remain open allowing ventilation in the bathroom, no mechanical ventilation was present. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The Provider issued a worker to fix the bathroom window. The bath room window was repaired on 10/28/22. It's operable with sufficient ventilation. Please see worker order invoice attachment. |
10/28/2022
| Implemented |
| 6400.77(c) | The first aid kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | The provide has provided a First Aid Kit with a first aid manual in it. |
11/09/2022
| Implemented |
| 6400.112(e) | Overnight drills are not held every six months. An overnight drill in August 2022, but no documented overnight drills between January and July 2022. | A fire drill shall be held during sleeping hours at least every 6 months. | The Provider will be consistent in conducting all recommended fire drill, including the Overnight according to PA Code Chapter 6400.112(e) to remain in compliance. |
11/09/2022
| Implemented |
| 6400.46(b) | Staff #1 was not trained in fire safety annually. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The provider will coordinate with the fire safety expert to conduct Agency wide Fire Safety training for all staff to include Staff # 1, according to PA Code Chapter 6400.64(b) |
11/09/2022
| Implemented |
| 6400.52(a)(3) | Staff #1 Training for current year not provided 24 hours of training related to job skills and knowledge. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | Commonwealth Supportive Services training year begins from January 1st to December 31 of each year. Training records for staff # 1 is attached for your review. |
11/09/2022
| Implemented |
| 6400.165(b) | PRN medication ACETAMINOPHEN 325mg was in Ind. #5 medication box but not listed on the MAR. | A prescription order shall be kept current. | The provider requested an updated current MAR from the Pharmacy. Please see attached MAR attached. |
08/22/2022
| Implemented |