| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1 financial record is incomplete. It shows a recurring monthly $20 charge, labeled "back rent" in their ledger. Documentation of the source or reason for this ongoing expense was requested but not provided by the agency. | (2) Disbursements made to or for the individual.
| This Individual had an outstanding Accrued Room & Board Agreement. Individual # 1 defaulted to pay her monthly Room & Board from December 9th. 2015 to April 30th. 2016 when she was her own Rep Payee. Please see Accrued Room & Board Agreement attached for your review. |
11/08/2022
| Implemented |
| 6400.65 | The skylight located in the upstairs 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.
| Commonwealth Supportive Services issued a worker to repair the Skylight in the bathroom of this home.And the skylight was fixed by 10/28/2022 Please see invoice attachment. |
10/20/2022
| Implemented |
| 6400.66 | There is not lighting coming down the basement or in the room immediately at the bottom of the steps. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A new light was fixed on the staircase immediately coming down the basement and the room at the bottom of the basement steps. Please see work order invoice attached. |
10/28/2022
| Implemented |
| 6400.72(b) | The basement screen door was damaged and need repaired | Screens, windows and doors shall be in good repair. | A new screen door was installed in the basement. |
10/28/2022
| Implemented |
| 6400.110(e) | The home has three stories which includes a basement, the smoke detectors are not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The Provider has installed interconnected smoke detectors on all three floors in this home including the basement. Please see invoice attached. |
10/28/2022
| Implemented |
| 6400.112(a) | Fire drills were not held in March and April 2022. Documentation of these drills was requested but not provided. | An unannounced fire drill shall be held at least once a month. | Moving forward, the house manager will ensure monthly fire drills are conducted. |
08/23/2022
| Implemented |
| 6400.141(a) | Greater than one year elapsed between Individual #1 two most recent physicals, dates 7/28/20 and 8/26/21. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Doctors office conducts annual physicals after a 12 month period because of insurance reasons. Program Specialist would work with the PCP office to get an appointment within two weeks after the 12 month period. |
11/08/2022
| Implemented |
| 6400.141(c)(4) | Individual #1 has not had an annual hearing screening. Records of annual hearing screenings were requested but not provided. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Program Specialist worked with the PCP and the form was completed in its entirety. Which indicate the annual hearing screening was done.Please see form attached. |
08/29/2022
| Implemented |
| 6400.141(c)(7) | Individual #1 has not had an annual OB/GYN exam with PAP test. Records of an exam were requested but not provided. | 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 had an OBGYN Exam with Pap Test on November 1 2022. Please see document attached for your review. |
11/01/2022
| Implemented |
| 6400.141(c)(8) | Individual #1 has not had an annual mammogram. Annual physical records from 8/26/21 indicate a mammogram was completed on 1/5/21; documentation of that and a current mammogram were requested but not provided. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual # 1 completed a Mammogram examination 0n May 17th. 2022 Please see proof of examination attached for your review. |
11/08/2022
| Implemented |
| 6400.142(a) | Individual #1 has not had an annual dental exam since 7/8/20. The agency provided documentation of one dental exam refusal from the individual, dated 11/29/21, but no documentation of further attempts to complete the visit. | 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. | Moving forward the provider will maintain records for all dental refusals by individual # 1. |
11/01/2022
| Implemented |
| 6400.144 | Individual #1 is borderline diabetic and her ISP and Annual Assessment states her blood sugar is monitored; this is not happening as her monitor is not being utilized and no log is kept. | 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 provider contacted individual # 1 PCP for a follow up on her pre-diabetic diagnosis. The PCP Office stated that the Individual does not require a blood sugar monitoring at this time. |
08/23/2022
| Implemented |