| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.66 | At 12:15PM on 11/20/2024, there was not a source of light outside the basement door leading to the side of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents. | On 12/6/24 the lights that were not operable were replaced in the basement door leading to the side of the home. |
12/06/2024
| Implemented |
| 6500.70 | At 12:00PM on 11/20/2024, the only telephone was in the office on the third floor of the home rendering it inaccessible to the individuals. | A home shall have an operable telephone that is easily accessible. | On 12/9/24 an operable telephone was installed in the second floor of the house and is accessible to the individuals living there. |
12/09/2024
| Implemented |
| 6500.74 | At 12:03PM on 11/20/2024, the eight interior stairs, in the basement leading to an exit on the side of the home, did not have a nonskid surface. At 12:05PM on 11/20/2024, the bottom interior step, in the basement leading to the first floor of the home, did not have a nonskid surface. | Interior stairs and outside steps that are accessible to individuals shall have a nonskid surface. | On 12/9/24 all the stairs that are accessible to the individuals have non skid surfaces installed. |
12/09/2024
| Implemented |
| 6500.101 | The following door locking mechanism pose an obstructed egrees and/or "choke point" when engaged. At 11:37AM on 11/20/2024, there was a sliding chain lock on the front exit door of the home. At 11:39AM on 11/20/2024, there was a sliding chain lock on the exit door in the kitchen of the home. At 11:41AM on 11/20/2024, there was a hook and eye lock on the storm door in the kitchen of the home. At 12:04PM on 11/20/2024, there was a slide lock on the exit door in the basement leading to the side of the home. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | On 12/6/24 all antique locks are unable to be used allowing all the doors unobstructed. |
12/06/2024
| Implemented |
| 6500.25 | Family Living Provider #2 assists Individual #1 with personal funds. On 11/6/2024, $30.00 was taken from Individual #1's funds to pay one third of the home's cable and internet expense. Interviews revealed that the two individuals in the home and Family Living Provider #1 have each been paying one third of this expense each month for an unknown timeframe. 55 PA Code 6100.684d(iii) requires that internet service be provided as part of room and board. | The home and agency shall comply with applicable Federal and State statutes and regulations and local ordinances. | On 11/22/24 the money was reimbursed back from July 2024. The individual is no longer paying for the internet or television services in the home. |
11/22/2024
| Implemented |
| 6500.132(a) | Family Member #1 administered Individual #1's prescribed medications from 11/1/2024 to 11/20/2024. Family Member #1 is not qualified to administer medications. | Staff persons or others who are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | On 12/6/24 had staff and or others that may provide medication administration trained on the ODP Medication Administration course. |
12/06/2024
| Implemented |
| 6500.133(d) | At 12:21PM on 11/20/2024, Individual #1's prescribed medications, Loratadine and Ibuprofen were unlocked and accessible on a shelf in the kitchen of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On 12/6/24 all medications were placed in a container that is locked. |
12/06/2024
| Implemented |
| 6500.152(c) | Individual #1's Service Plan, last updated 11/21/2024, reads, "[Individual #1] is able to exit the building within 2 1/2 minutes with verbal prompting." Individual #1's assessment, completed 8/30/2024, states that Individual #1 can exit during a fire drill independently. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 11/21/24 staff updated the DAT after reviewing the information on paper and with the team to reflect the ISP. |
11/21/2024
| Implemented |