| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The home did not have a working tub or shower for the individual usage. Water was observed on the floor in 2 locations of the basement. | Floors, walls, ceilings and other surfaces shall be in good repair. | Consumer's bathroom Shower was repaired on 7/15/2025. Water in basement mopped from floor. |
07/15/2025
| Implemented |
| 6400.76(a) | The dresser drawers in the individuals bedroom was not sturdy and on track posing a potential falling hazard. One of the dresser drawers did not have a knob to open the drawer. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Individual #3 new dresser was purchased replacing the old one on 7/10/2025. |
07/10/2025
| Implemented |
| 6400.112(d) | Fire drills completed in the last 12 months from June 2024 until June 2025 all exceeded the allowed 2min and 30 second evacuation time. The facility does not have an approved extended evacuation letter from a fire safety expert on file. Documented evacuation times are between 5 minutes 11 seconds to 13 minutes 14 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A Fire letter was resubmitted to the Fire Department on 8/31/2025 requesting the additional evacuation time of 10 minutes, because the extensive medical needs of the individual #3. Additionally, Olalus was instructed to send the fire letter to a different address. The letter was delivered by the house manager to the Fire Chief of Darby Township Fire Company. The fire chief promised to send a response within a week. Olalus will therefore follow-up on Friday, October 3, 2025, if we do not receive a response by said date. |
08/31/2025
| Implemented |
| 6400.112(f) | Fire drills documented from June 2024 thru June 2025 did not use alternate exit routes. All fire drills completed from June 2024 thru June 2025 used the front exit. | Alternate exit routes shall be used during fire drills. | Fire drill training completed for the team on 8/26/2025 of the section of the fire safety in 6400 Regulatory Compliance Guide explaining the process of the Alternate exit routes used in this home. |
08/26/2025
| Implemented |
| 6400.113(a) | Fire safety training for individual 3 was held on 03/01/25 and the previous training was held on 01/28/24, which is greater than a year apart. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Fire safety training complete for the team within the 6400 Regulatory Compliance Guide 8/26/2025. |
08/26/2025
| Implemented |
| 6400.142(a) | 02/16/23 dental report for individual 3 states patient allowed exam, but did not allow any treatment to be completed; no refusal forms or treatment counselling. | 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. | A refusal form completed by Medical Coordinator with Individual #3, counseling the individual on the importance of the dental exams and new appointment made 9/18/2025 |
07/15/2025
| Implemented |
| 6400.142(g) | There was no dental hygiene plan in the past year for individual 3. | A dental hygiene plan shall be rewritten at least annually. | Medical Coordinator completed the dental plan for individual #3. |
07/09/2025
| Implemented |
| 6400.171 | Several open and used food items that state "refrigerate after opening" were observed in the kitchen cabinet (2 bottles of salad dressing, a tub of butter, nacho cheese dip, and grated parmesan cheese). | Food shall be protected from contamination while being stored, prepared, transported and served.
| Site Manager removed open salad dressing and disposed of the bottles. All food is stored in the correct manner in the cabinet. |
07/07/2025
| Implemented |
| 6400.181(c) | The ISP was not updated to report that there is no restrictive plan for individual 3's telephone use. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | A meeting with Support Coordinator, Program Specialist, Site Manager and Individual #3 was conducted on 7/24/2025 discussing the changes needed to the ISP to reflect no restrictive procedures in Individual's #3 plan. |
07/24/2025
| Implemented |
| 6400.32(r) | Individual 3 - There was no lock on the individual's bedroom door. ISP did not state a discussion was held with the individual regarding not to have a lock. | An individual has the right to lock the individual's bedroom door. | Individual #3-bedroom received a lock on the door on 7/15/2025 for privacy. |
07/15/2025
| Implemented |
| 6400.32(t) | 01/01/25 individual rights form for individual 3 did not include the right to access food at any time. | An individual has the right to access food at any time. | Program Specialist corrected the individual rights was updated for Individual #3 to read and sign. |
07/08/2025
| Implemented |
| 6400.165(g) | A Psychiatric medication review for individual 3 was done on 08/12/24 and the next review was not done until 02/03/25. | 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. | Medical Coordinator has received two copies of current 90-day medication reviews completed for Individual #3 for last 6 months. |
07/31/2024
| Implemented |
| 6400.183(c) | The ISP team meeting signature page for individual 3 was not present in the individual's record. | The list of persons who participated in the individual plan meeting shall be kept. | Program Specialist received a copy of ISP signature page 2024/2025 and ISP signature page 2025/2026 Plan. |
07/16/2025
| Implemented |