| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 had an eye exam completed on 11/27/24 which reflects she has a new eye glass prescription. This documentation also reflects the individual shall return in one year. There was no documentation that reflects the individual received new glasses in 2024 or that a follow eye exam was completed by 11/2025. The agency provided follow up documentation which reflects the individual had an eye apt on 12/22/25 and received a new eye glass script. Health services were not provided in a timely manner. | 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.
| Upon further review, it was confirmed that the individual refused to obtain glasses in 2024. Refusal documentation was completed at that time and signed by the individual, and this documentation has now been filed in the medical record.
The follow-up eye appointment originally scheduled within the recommended timeframe was rescheduled due to a snowstorm on the day of the appointment. A Communication with Physician form has been completed to document the cancellation and rescheduling of the appointment to December 2025. The individual was seen on 12/22/2025, received a new eyeglass prescription, and a new pair of glasses was purchased on 1/7/2026. Documentation of the completed appointment, new prescription, and proof of purchase of the glasses has been placed in the individual's record. |
03/02/2026
| Implemented |
| 6400.18(a)(8) | The home shall report an incident, alleged incident and suspected incidents through the departments information management system within 24 hours of discovery which include law enforcement activity that occurs during the provision of a service for an individual. It was discovered while investigating an incident that occurred on 1/25/26 surrounding an alleged rape, that the police were also called to individual's residence on Saturday 1/24/26. It was reported that the individual wanted her guest to leave and he would not leave and she contacted the police who escorted the guest out of the home. This incident involved the individual contacting the Wilkes Barre Police Dept who arrived and removed the guest from the home. This incident was not reported in the appropriate time frame. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| Administrative staff were made aware of the incident on 2/20/2026, at which time the incident was immediately entered into the Enterprise Incident Management (EIM) system under EIM #9791305. |
02/20/2026
| Implemented |
| 6400.45(e) | Individual may not be left unsupervised soley for the convenience of the home or worker. It has been reported by agency staff that individual #1 often asks staff to leave her home. In this instance the staff will leave, and the individual will utilize her alone time. Individual has 8 hours of alone time to utilize during the day. On 1/25/26 and 1/26/26 the house supervisor contacted individual #1 to inquire if she wanted to use her alone time today. Staff explained that due to the snowstorm, the agency vehicles are grounded and will not be used. It was reported that individual #1 chose to use her alone time on those days. It appears that on a typical day staff report to work, and if the individual choses to use her alone time, she asks staff to leave. It is not typical that staff contact the individual prior to a shift to inquire if she rather use alone time or have staff come into work. It appears that the individual was asked prior to the staff shift if she would rather use her alone time due to convenience of the staff not having to come into work during the snow storm. | An individual may not be left unsupervised solely for the convenience of the home or the direct service worker. | Individual #1 Supervision Back-Up Plan has been reviewed and updated to ensure her health, safety, and personal choice remain the primary focus during situations that may impact in-person staffing. The updated plan clarifies that in the event of a staffing disruption due to unforeseen circumstances such as a staff emergency or inclement weather, Individual #1 will be contacted and informed of the situation. She will be asked whether she would like in-person staff support that day or prefers to utilize her approved unsupervised time and on-demand remote support services, consistent with her assessed needs and authorized service plan.
If Individual #1 chooses to receive in-person support, the provider remains fully responsible for securing appropriate staffing coverage. In situations involving inclement weather, if roads are unsafe, staffing will be arranged as soon as conditions allow safe travel. If Individual #1 elects not to have in-person staff during these circumstances, she may utilize her unsupervised time and approved remote support services as outlined in her plan. |
02/20/2026
| Implemented |