| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Support Professional #1's date-of-hire is 11/8/24. The agency completed a Pennsylvania criminal history check to the State Police on 10/31/24, revealing a final report of criminal history involvement. However, the agency did not provide documentation of a criminal record review outlining their consideration for hiring Direct Support Professional #1 based on the following factors: the nature of the crime; the facts surrounding the conviction; the time elapsed since the conviction; the evidence of Direct Support Professional #1's rehabilitation; and the nature and requirements of the job. [Repeated Violation-2/1/24 et al] | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| COO received retraining on regulation 6400.21a on 2.25.2025 - proof of this training will be provided to the licensing representative supervisor upon submission of this plan.
Liberty Holding COO revised the Staff Screening Requirements Procedure to include clear language about the screening process and provided training to the Program Manager who will serve as designee to complete the screenings in the absence of the COO.
An employment screening was completed regarding Direct Support Professional #1. Proof of all trainings, procedure revision and staff screening documentation will be emailed to the licensing representative supervisor upon submission of this plan. |
02/28/2025
| Implemented |
| 6400.166(a)(5) | On 2/11/25 the February 2025 Medication administration record for Individual number one was missing the strength of the prescribed pro re nata Robitussin and Tylenol. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The Clinical Director and House Manager received retraining on regulation 6400.166(a)(5) on 2.24.2025.
Individual number one's MAR has been corrected to include the strength of the medication for pro re nata Robitussin and Tylenol. Proof of retraining and the MAR documentation will be emailed to the licensing representative supervisor upon submission of this plan. |
02/24/2025
| Implemented |
| 6400.166(a)(6) | On 2/11/25 the February 2025 Medication administration record for Individual number one was missing the dosage form of the prescribed pro re nata Robitussin and Tylenol. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The Clinical Director and House Manager received retraining on regulation 6400.166(a)(6) on 2.24.2025.
Individual number one's MAR has been corrected to include the dosage form of the medication for pro re nata Robitussin and Tylenol. Proof of retraining and the MAR documentation will be emailed to the licensing representative supervisor upon submission of this plan. |
02/24/2025
| Implemented |
| 6400.166(a)(7) | On 2/11/25 the February 2025 Medication administration record for Individual number one was missing the dose of the prescribed pro re nata Robitussin and Tylenol. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Clinical Director and House Manager received retraining on regulation 6400.166(a)(7) on 2.24.2025.
Individual number one's MAR has been corrected to include the dose of the medication for pro re nata Robitussin and Tylenol. Proof of retraining and the MAR documentation will be emailed to the licensing representative supervisor upon submission of this plan. |
02/24/2025
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan, last updated on 12/30/24, was not revised to reflect their current needs as based on their current assessment, completed on 9/13/24, in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Individual Support Plan left this skill domain completely unaddressed, while their assessment indicated that Individual #1 can sense and quickly move away from such heat sources; and regarding supervision within the home and community, Individual #1's Individual Support Plan explained that they can be left alone at home for up to four hours, but staff are required to be within auditory range at all other times while conducting 15-minute visual checks whenever Individual #1 is outside on the property. Their Individual Support Plan further stated that when in the community, staff are required to always be within eyesight of Individual #1. However, Individual #1's assessment indicated that they can be left alone in the home for up to two hours, but for all other times in the home, although required to always be aware of where Individual #1 is, staff are not required to be within eyesight of Individual #1. In the community, Individual #1's assessment stated that staff must always remain within earshot of Individual #1. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | All Program Specialists received retraining on regulation 6400.182(c) on 2.24.2025. The Program Specialist emailed individual #1's SC to request revisions to the indicated ISP sections that reflect inaccurate supervision care needs in an effort to make the ISP congruent with the assessed need. Once all requested revisions have been confirmed, the Program Specialist will send the ISP to the House Manager for the revised plan to be trained on promptly. Upon submission of this plan, an email containing proof of training and the email notification sent to the SC will be sent to the licensing representative supervisor. Once the ISP has been updated and all staff trained accordingly, proof of that training will also be emailed to the licensing rep.
The Program Specialist also updated individual #1's current annual assessment to provide clarification of assistance/supervision needed around heat sources after ensuring that this information is congruent to the ISP, sent the revisions to the home to be trained on by all DSP's and proof of the assessment update and training will be provided to the licensing representative supervisor upon submission of this plan. |
02/28/2025
| Implemented |