| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a strong odor consistent with the smell of urine throughout the home. | Clean and sanitary conditions shall be maintained in the home. | All safe and chemically responsible home cleaning measures are continuing to be implemented to ensure clean and sanitary conditions are continually maintained in the home. Due to individual incontinence, it is impossible to completely eliminate urine odor in the home. |
10/31/2021
| Implemented |
| 6400.113(a) | A new fire safety training was needed when the Individual 1 moved into this home. The latest fire safety training on file, dated 1/30/21, took place at the individual's previous address. | 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 has been completed for the Individuals new address. Program Specialist has received additional training to ensure that Individuals receive Fire Safety Training as per 55 PA Code Chapter 6400.113(a). |
08/05/2021
| Implemented |
| 6400.142(a) | Individual 1's last dental exam occurred on 9/27/19. | 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 dental examination has been scheduled for Individual 1 for 10/19/2021 |
10/19/2021
| Implemented |
| 6400.142(f) | There was no dental hygiene plan in Individual 1's individual record. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | A dental hygiene plan has been added to Individual 1's record. |
08/05/2021
| Implemented |
| 6400.144 | Several medications prescribed for Individual 1 were not present in the home at the time of inspection:
1. Fluticasone/Salmeterol Aerosol Disc - Medication not present at the time of inspection, but administering staff signed off on the Medication Administration Record (MAR) as if it were given the morning of the inspection at 8:00am (8/4/21).
2. Levothyroxin 25mcg Tablet - Medication not present at the time of inspection, but administering staff signed off on the MAR as if it were given the morning of the inspection at 8:00am (8/4/21).
3. Flucatisone Nasal Spray 50mcg pro re nata (PRN) - Medication not present in the home at the time of inspection.
4. Lactulose 10 gm PRN - Medication not present in the home at the time of inspection. | 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.
| Fluticasone/Salmeterol Aerosol Disc, Levothyroxin 25mcg, Flucatisone Nasal Spray 50mch, and Lactulose 10gm have been placed in the home of Individual 1 for use. |
08/05/2021
| Implemented |
| 6400.181(d) | The Program Specialist did not sign and date Individual 1's assessment. | The program specialist shall sign and date the assessment. | Program Specialist has signed and dated Individual assessment |
08/05/2021
| Implemented |
| 6400.181(e)(8) | Individual 1's assessment was vague about the individual's ability to evacuate in the event of a fire. The assessment states that Individual 1's motor skills have declined, and the individual uses a wheelchair and walker around the house. The assessment states only that Individual 1 knows they must evacuate quickly; it does not state what level of assistance the individual would need to do so. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | The assessment has been updated to reflect the level of assistance the individual would need to evacuate in the event of a fire. |
08/05/2021
| Implemented |
| 6400.183(c) | No list of the participants in Individual 1's most recent Individual Support Plan (ISP) team meeting was located within Individual 1's individual record. | The list of persons who participated in the individual plan meeting shall be kept. | ISP Sign in sheet has been filed in Individual 1 program chart. |
08/05/2021
| Implemented |