|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | There was no screen in the basement shower room's window. As there was no screen available within the home that could be placed within this window should it be opened, it was incapable of being securely screened when in use. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The screen for this window will be replaced on 08/09/2024. |
08/09/2024
| Implemented |
| 6400.106 | The latest furnace inspection on record for this location was conducted on 10/25/2022. There was no evidence of a more recent furnace inspection occurring. The furnace at this location was not inspected annually as required. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace was inspected on 7/17/24. |
07/17/2024
| Implemented |
| 6400.112(h) | Individual #4 and Individual #5 reside together at this location. The provider explained that this home is treated as "two separate programs" and, thus, fire drills were completed separately for each of the individuals. There was a separate record of fire drills conducted for each individual throughout the 2023-2024 calendar year. Although the provider treated this location as a two separate homes for the fire drills, the location is not formally subdivided and, though they live in separate areas of the home, the individuals reside together at the location, which is a single residence. Further, there is one fire alarm system shared between both of the individuals' living areas within the residence.
Per the fire drill records, Individual #4 completed fire drills on: 07/18/2023, 08/12/2023, 09/23/2023, 10/27/2023, 11/09/2023, 12/05/2023, 01/16/2024, 02/09/2024, 03/25/2024, 04/14/2024, 05/06/2024, and 06/16/2024, while Individual #5 completed fire drills on 09/06/2023 (Initial upon move-in), 10/25/2023, 11/09/2023, 12/05/2023, 01/16/2024, 02/09/2024, 03/16/2024, 04/14/2024, 05/06/2024, and 06/16/2024. Per the provider's documentation, where the aforementioned dates do not overlap, Individual #4 did not evacuate during the fire drills designated for Individual #5 and vice versa. All individuals within the home must evacuate to a designated meeting place during each fire drill. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | For the month of July this site drill was complete with both individuals. The staff in the home were trained on how to complete our monthly drills and fire safety education with both individuals. |
07/20/2024
| Implemented |
| 6400.15(b) | The self-assessment of this location, conducted 06/01/2024, was completed on the Department's "Self-Inspection and Declaration Tool," which is intended to be used for opening a new location, rather than the Department's "Self-Assessment Licensing Inspection Instrument," which is intended to be used for the annual self-assessment of a location. In addition, the self-assessment was not completed at least 3-6 months prior to the provider's 07/12/2024 license expiration date. As such, there was no valid self-assessment conducted for this location as is required within the specified time frame. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Standard Operating Procedure was created for the Residential Licensing process. |
08/31/2024
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.52(c)(1) | Staff # 1 and #2 did not receive training during training year 7/02/2021 to 6/30/2022 in the following area: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff 1 & 2 were brought in and person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships was administered within 48 hours of notification of the violation. |
08/05/2022
| Implemented |
| 6400.52(c)(2) | Staff # 1 and #2 did not receive training during training year 7/02/2021 to 6/30/2022 in the following area: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff 1 & 2 were brought in and given all required abuse trainings within 48 hours of notification of the violation. |
08/05/2022
| Implemented |
| 6400.52(c)(3) | Staff # 1 and #2 did not receive training during training year 7/02/2021 to 6/30/2022 in the following area: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff 1 & 2 were brought in and given individual rights trainings within 48 hours of notification of the violation. |
08/05/2022
| Implemented |
| 6400.52(c)(4) | Staff # 1 and #2 did not receive training during training year 7/02/2021 to 6/30/2022 in the following area: Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff 1 & 2 were brought in and given recognizing and reporting incidents within 48 hours of notification of the violation. All LVAS staff will be taking Recognizing and reporting incidents by 8/29/22. |
08/05/2022
| Implemented |
| 6400.52(c)(5) | Staff # 1 and #2 did not receive training during training year 7/02/2021 to 6/30/2022 in the following area: The safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff 1 & 2 were brought in and given behavior supports training within 48 hours of notification of the violation. The HCQU will be out to provide behavior de-escalation on 9/6/22 |
08/05/2022
| Implemented |
|
|