| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Based upon the expiration of the certificate of compliance the self-inspection of the home should have been completed between 9/4/24 and 1/4/25. The self-inspection submitted for review was completed on 2/5/25. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| This reg. is important to measure the record of compliance with the chapter
When I got the instructions about doing self-assessment between the date of the letter to the date of the inspection, I only presented the current one to the inspector. Even though I did the previous one in November and December of 2024. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025 |
03/06/2025
| Implemented |
| 6400.21(e) | At the time of inspection Individual #1 was the only Individual residing in the home and was admitted on 11/18/24. The date of birth provided by the agency for Individual #1 indicates that they were 17 years old at the time of inspection on 3/5/25.
Staff #2 has a documented hire date of 9/30/24 and a first day with individuals date of 11/23/24. Records indicate that a child abuse clearance was not completed until 11/27/24.
Staff #3 has a documented hire date of 1/2/25 and a first day with individuals date of 1/17/25. Records indicate that a child abuse clearance was not completed until 1/27/25. | If the home serves primarily individuals who are 17 years of age or younger, 23 Pa.C.S. § § 6301¿6384 (relating to the Child Protective Services Law) applies. | It is important to keep in compliance with this reg. to ensure the protection of the individuals. A child abuse clearance for Staff members were not completed before working with a child. Marion Reid clearance was done on 11/21/24 and her first home orientation was on 11/23/24. Staff Valerie Thomas clearance did not go through due to her putting in her personal information wrong and she had to redo the clearance. |
03/07/2025
| Implemented |
| 6400.141(a) | Records indicate that Individual #1 was admitted into the program on 11/18/24. The physical submitted for review was dated as completed on 12/3/24. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Regulation is important for the health and well-being of the individual. The individual physical was not done before moving into the CLA. The individual came from Kidz Peace, and their physical did not correspond with that of ODP reg. Our form was sent to the doctor to fill out the form, but it was never filled out and we had to do another physical. |
03/21/2025
| Implemented |
| 6400.181(a) | Records indicate that Individual #1 was admitted into the program on 11/18/24. The assessment presented for Individual #1 was dated as completed on 2/7/25, outside of the required 60 days. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Initial assessment is important for the individual¿s team to understand and know how to support the individual. During the inspection, the initial assessment was not done within the required time. The program specialist did the initial assessment within the 60 days period; however, the SC did not schedule the ISP in the 90 days¿ time frame. Therefore, the PS changed the initial date to reflect the ISP review date. |
03/24/2025
| Implemented |
| 6400.52(c)(1) | There was no documentation that Staff #1 had training on individual choice and supporting individuals to develop and maintain relationships during the provider established 2024 calendar training year as required. | 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. | Training is important to maintain quality support for the individual. At the time of the inspection, Staff #1 did not have 2024 individual choice training. Staff #1 did all the required training as a manager with additional training. Individual choice and relationship are covered under the Individual Right and person center training which were done. |
03/24/2025
| Implemented |