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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(f) | The fire drill conducted 10/20/2022 had the individuals use the garage door as the exit route. The garage does not contain a swing door as an egress. | Alternate exit routes shall be used during fire drills. | The Fire Drill form and the Fire Drill Policy was updated on 5/4/2023 (Pic #5) to include the statement that a garage door cannot be used as a fire drill exit. A fire drill using the updated form was run on 5/4/2023 with all individuals present. (Pic #7) Staff discussed with the individuals that they would not be using the garage door as a fire drill exit. [Documentation of the Fire Drill Policy and TLHHC Monthly Fire Drill Report were received on 5/10/23 and reviewed 5/22/23. Documentation of training for all residential staff, completed between 5/6/23 and 5/9/23, related to "POC Training: Running Water, Surfaces and Lighting, Unobstructed Egress, Fire Evacuation" was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
| 6400.32(r)(4) | Individual #1 and Individual #2 had a privacy lock on their bedroom doors which does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The Privacy Lock Policy was updated on 5/4/2023 to include the updated language that bedroom doors should be equipped with a key lock to the outside and a doorknob tab on the inside. (Pic #10) The two bedroom door¿s doorknobs was replaced with a key lock on the outside and a doorknob tab on the inside on 5/6/2023. (Pic #11) The individuals were trained on the updated policy on 5/6/2023. (Pic #12) [Privacy Lock Policy that includes that "[d]oors shall be equipped with a key lock on the outside and a thumb-turn lock on the inside" was received on 5/10/23 and reviewed 5/22/23. Documentation via photograph that door locks, in accordance with the agency's policy, have been installed was received on 5/10/23 and reviewed 5/22/23. Documentation that Individual #1 and Individual #2 were retrained on the Privacy Lock Policy, dated 5/6/23, was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
06/04/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1had a physical examination on 01/15/2020, and then again on 04/13/21. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 1. As recommended by the Licensing, on 4/23/2021, in response to the seemingly unreliable current PCP, Health/IDD Manager approached Individual#1 and Individual#1¿sister, discussing the current Health Choice for Individual #1, offering an option to choose another healthcare provider for PCP. Individual#1 agreed with Individual#1¿s sister to not change the PCP.
2. On 5/6/2021, Health/IDD Manager, by contacting UPMC Connect was able to be connected by phone with PCP office and set up PCP appointment for Individual#1¿s Physical for 1/5/2022.
3. Health/IDD Manager received a call that might be due to UPMC¿s intervention; PCP will send the completed 1/5/2021¿s physical summary form. However, due agency could not predict the realization of it. Agency will send the completed 1/5/2021¿s Indivdiual#1¿s physical as soon as it has been received.
4. CCO will submit the signed Individual #1¿s Health Choice, outlook reminder and Therap schedule for Individual #1's 1/5/2022's annual physical appointment on 5/7/2021. [Verification of Individual #1 scheduled appointment for 1/5/2022, Outlook reminder, and Individual #1 Healthcare Choice form on 5/21/21. Verification of agency's Medical Appointment Policy and Procedure, dated 4/26/21, on 5/21/21. DPOC by HDKP, HSLS, on 5/21/21]. |
05/07/2021
| Implemented |
| 6400.15(b) | The agency completed a self-assessment inspection on 12/08/20 and 03/13/21 but did not use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | 1. On 4/22/2020¿s Team Meeting, CEO decided that agency will conduct self-inspection to all houses except Logan Ferry using Self-Inspection in Appendix in RCG. On 4/23/2021, CEO, CCO, Program Specialist, QA/CO, and Health/IDD Manager met to go over each section of the RCG and Self-Inspection. Team learned that they are more items added. However, we gladly have documentations from 2019 pertaining to individual rights.
2. Self-inspection using new tools were completed:
a. On 4/30/2021 at Dorothy House and Greenfield House
b. On 5/1/2021 at Green Tree House and Highland House
c. On 5/2/2021 at Braun House, Delmont House, and Rubco House
3. On 5/3/2021, during team meeting, was the finalization of Self-Assessment Completion.
4. CCO will submit the completed self-inspection on 5/7/2021
5. CCO will submit all the meeting signature sign-in sheets and meeting minutes on 5/7/2021. |
05/07/2021
| Implemented |
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