| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this site on 5/1/24, did not provide a written summary of corrections made for either of the following violations identified: .52c1 and .168a. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| A summary of corrections made on the violations identified in the self-assessment was documented on 6/28/2024. A copy of the self-assessment results and the written summary of corrections is kept in the home. |
06/28/2024
| Implemented |
| 6400.65 | At 2:58 PM on 6/12/24, the half bathroom located in the basement was observed without a mechanical vent, air duct, or operable window for ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Solidarity Management contacted the Handyman on 6/12/2024 and an operable window was installed on 6/16/2024. |
06/16/2024
| Implemented |
| 6400.101 | At 2:52 PM, The basement door leading into the attach garage was observed with two sliding latch locks---one at the top and one at the bottom---and two dead-bolt locks operated by key. The key-side on both deadbolt locks was facing the garage, which did not have a man door exit to the outside, creating a blocked egress. [Repeated Violation-9/20/23, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Solidarity Management contacted the Handyman on 6/12/2024 and the two sliding latch locks on the basement door leading into the attach garage were removed on 6/16/2024. |
06/16/2024
| Implemented |
| 6400.105 | At 2:57 PM on 6/12/24, the dryer vent outside of the home in the backyard was found with a crumbled-up piece of foil lodged in its opening, preventing the flow of heat, dust, and linen from escaping the dryer hose located inside the basement. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Solidarity Management contacted the Handyman on 6/12/2024 and the crumbled-up piece of foil lodged in its opening was removed on 6/16/2024. |
06/16/2024
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 3/15/24, did not include information pertinent to diagnosis and treatment in the case of an emergency. This field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 6/26/24, the medication administration trainer trained all house leads on how to complete the individual physical examination records to ensure the physical examination includes information pertinent to diagnosis and treatment in the case of an emergency. |
06/26/2024
| Implemented |
| 6400.181(d) | Individual #1's most recent assessment completed on 10/5/23, was not signed by the program specialist. | The program specialist shall sign and date the assessment. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to include signature and date of assessment. |
06/17/2024
| Not Implemented |
| 6400.181(e)(10) | Individual #1's most recent assessment completed on 10/5/23, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to include a lifetime medical history of the individual. |
06/17/2024
| Not Implemented |
| 6400.165(g) | Individual #1's date-of-admission is 10/27/22, and they are prescribed medication to treat symptoms of a psychiatric illness. Individual #1's first medication review was not completed until 1/3/24. Subsequent medication reviews were conducted on 3/27/24 and 6/12/24. However, the following information was found missing from the three medication reviews documented for Individual #1: the specific medications reviewed on 1/3/24 and 3/27/24, along with their corresponding dosages and reasons for prescribing were missing; and the need to continue taking the medications reviewed on 6/12/24 was not provided. [Repeated Violation-9/20/23] | 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. | The former Program Specialist left the organization in December 2023. The Program Specialist designed a Psychiatric Medication review template on June 13, 2024, ensuring the review every 3 months by a licensed physician documents the reason for prescribing the medication, the need to continue the medication and the necessary dosage. |
06/13/2024
| Implemented |
| 6400.182(c) | Individual #1's most recent assessment completed on 10/5/23, indicates they are independent in fire evacuation. However, Individual #1's individual plan last updated on 6/4/24, informs that they require physical assistance to evacuate safely in the event of a fire. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The former Program Specialist left the organization in December 2023. The new Program Specialist designed a new assessment template on 6/17/2024 to comply with Pa 6400.181 and ensure that the initial individual plan is developed based on the individual assessment within 90 days of the individual's date of admission to the home. |
06/17/2024
| Not Implemented |