| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The lighting outside of the downstairs front door was not operable at the time of inspection on 9/14/21. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The house supervisor immediately switched the light bulb. the Supervisors is expected to walk through their programs daily to have a visual check of all property. A Safety Review Form is to be completed for anything that needs fixed or repaired that can not immediately rectified so appropriate maintenance is brought in. to ensure all repairs are timely completed. |
09/22/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's vision was screened on 1/10/20 and not again until 3/2/21; which is outside of the annual time frame. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Supervisor will ensure this is adequately documented what the recommendation is for these tests and ensure they are completed in the timeframe suggested they will also track this by the monthly tracking form. |
09/22/2021
| Implemented |
| 6400.145(1) | The Emergency Medical Plan developed for The Arc of Centre County is the same for all households. There is only one emergency medical plan developed. The Emergency Medical Plan is to be individual specific and is to identify the individual's hospital of preference. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | This policy was updated to reflect preference of hospital for each individual resigning in a 6400 licensed residential home and how they will be transferred, as well as reflect emergency situations. |
09/22/2021
| Implemented |
| 6400.165(g) | Individual #1 had their quarterly psychiatric medication review on 8/25/20 and not again until 2/8/21. | 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. | The program supervisor ensured the monthly appointment documentation is updated and adequately tracked. if appointment is rescheduled or cancelled the appropriate documentation will be kept in the medical file for correspondence and what the steps are to be taken to achieve the appointment. |
09/22/2021
| Implemented |
| 6400.166(a)(2) | Individual #1 September 2021 Medication Administration Record does not include the prescribing physicians' names. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Supervisors and Program Specialists will ensure that the MARS have all required information. All MARs were immediately updated with the prescribing physician. |
10/01/2021
| Implemented |
| 6400.166(a)(11) | Individual #1 September 2021 Medication Administration Record (MAR) does not include the diagnosis or purpose for each medication listed on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Supervisors and Program Specialists will ensure that the MARS have all required information. All MARs were immediately updated with the diagnosis of the medications. |
10/01/2021
| Implemented |