| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(3) | Individual #1, date of admission 5/31/2024, does not have verification of having a tetanus immunization. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The CPS Program Director educated and trained the Program Specialist on the need to have all information completed on the individuals annual physical. Program Director then had the Program Specialist review 2380.111 regulations. A procedure was then developed to track the need to have all sections on the physical completed from 4/25/25 till 4/24/26. A letter will be attached to the physical form and sent home stating that in accordance with regulation 2380.111 the physical form needs to be filled out entirely. This means that each section needs to contain pertinent information, not applicable (n/a) or a slash mark. If there is any missing information, the form will not be accepted. |
04/25/2025
| Implemented |
| 2380.111(c)(6) | Individual #4's physical examination, completed 9/17/2024, did not address communicable disease. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | The CPS Program Director educated and trained the Program Specialist on the need to have all information completed on the individuals annual physical. Program Director then had the Program Specialist review 2380.111 regulations. A procedure was then developed to track the need to have all sections on the physical completed from 4/25/25 till 4/24/26. A letter will be attached to the physical form and sent home stating that in accordance with regulation 2380.111 the physical form needs to be filled out entirely. This means that each section needs to contain pertinent information, not applicable (n/a) or a slash mark. If there is any missing information, the form will not be accepted. |
04/25/2025
| Implemented |
| 2380.111(c)(7) | Individual #4's physical examination completed 9/17/2024 did not include health maintenance needs and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The CPS Program Director educated and trained the Program Specialist on the need to have all information completed on the individuals annual physical. Program Director then had the Program Specialist review 2380.111 regulations. A procedure was then developed to track the need to have all sections on the physical completed from 4/25/25 till 4/24/26. A letter will be attached to the physical form and sent home stating that in accordance with regulation 2380.111 the physical form needs to be filled out entirely. This means that each section needs to contain pertinent information, not applicable (n/a) or a slash mark. If there is any missing information, the form will not be accepted. |
04/25/2025
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination, completed 5/21/2024, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. Individual #2's physical examination, completed 6/24/2024, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. Individual #4's physical examination, completed 9/17/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The CPS Program Director educated and trained the Program Specialist on the need to have all information completed on the individuals annual physical. Program Director then had the Program Specialist review 2380.111 regulations. A procedure was then developed to track the need to have all sections on the physical completed from 4/25/25 till 4/24/26. A letter will be attached to the physical form and sent home stating that in accordance with regulation 2380.111 the physical form needs to be filled out entirely. This means that each section needs to contain pertinent information, not applicable (n/a) or a slash mark. If there is any missing information, the form will not be accepted. |
04/25/2025
| Implemented |
| 2380.173(1)(ii) | Individual #4's record did not include the color of the individual's eyes. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The CPS Program Director educated and trained the Program Specialist on the need to have all information completed on each individual¿s Personal Form. Program Director then had the Program Specialist review 2380.173 regulation. Program Director will review each individuals Personal Form to make sure that each section is completed. This will be done 4/25-30/2025 and then annually in April |
04/25/2025
| Implemented |
| 2380.173(1)(v) | Individual #1's record included a photograph dated 7/21/2023. Individual #4's record included a photograph dated 3/17/2024. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | Plan of Correction
The CPS Program Director educated and trained the Program Specialist on the need to have a current (yearly or when appearance changes) photograph in each individual¿s Personal Form. Program Director then had the Program Specialist review 2380.173 regulation. Program Director will review each individuals Personal Form to make sure that a new photograph is added. This will be done 4/25-30/2025 and then annually in April |
04/25/2025
| Implemented |
| 2380.181(e)(1) | Individual #1's assessment, completed 7/9/2024, does not address needs. This section reads, "none currently." Individual #1's assessment, completed 7/9/2024, does not include preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The CPS Program Director educated and trained the Program Specialist on the new section (Preference) in the assessment and using a complete thought/sentence and not ¿none currently¿. The CPS Program Director then had the Program Specialist review 2380.181 regulations. A procedure was then developed to track the addition of this section for assessment from 4/25/25 till 4/24/26. |
04/25/2025
| Implemented |
| 2380.181(e)(2) | Individual #1's assessment, completed 7/9/2024, does not address dislikes. This section was blank. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | The CPS Program Director educated and trained the Program Specialist on the new section (¿Likes, Dislikes and Interests of the individual, including vocational employment interests¿.) The CPS Program Director then had the Program Specialist review 2380.181 regulations. A procedure was then developed to track the addition of this section for assessment from 4/25/25 till 4/24/26. |
04/25/2025
| Implemented |
| 2380.181(e)(11) | Individual #1's assessment, completed 7/9/2024, did not include a psychological evaluation. Individual #3's assessment, completed 1/28/2025, did not include a psychological evaluation. Individual #4's assessment, completed 2/14/2025, did not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | The CPS Program Director educated and trained the Program Specialist on the need to include information pertaining to the Psychological Evaluation. CPS Program Director then had the Program Specialist review 2380.181 regulations. A procedure was then developed to track the addition of this section for assessment from 4/25/25 till 4/26/26. A letter/email will be sent to each individual¿s Support Coordinator asking for a copy of their Psychological Evaluation. A copy of the letter/email will be added to their file. |
04/25/2025
| Implemented |
| 2380.181(e)(12) | Individual #1's assessment, completed 7/9/2024, does not include recommendations for specific areas of training, vocational programming, and competitive community-integrated employment. This section reads, "none currently." | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The CPS Program Director educated and trained the Program Specialist on the new section (¿Recommendations for specific areas of training, vocational programming and competitive community-integrated employment¿)The CPS Program Director then had the Program Specialist review 2380.181 regulations. A procedure was then developed to track the addition of this section for assessment from 4/25/25 till 4/24/26. |
04/25/2025
| Implemented |
| 2380.37(a) | The training records for Chief Executive Officer #1's required trainings for the annual training year, 7/1/2023 through 6/30/2024, including the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, individual rights, and recognizing and reporting incidents were reportedly completed via, "Independent Study" and do not include the training sources and content of the trainings. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | The source of the Annual Required Training has been uploaded into our MITC system so that the source appears on the training report and training document. |
04/25/2025
| Implemented |
| 2380.182(c) | Individual #3's assessment, completed 1/28/2025 assesses that Individual #3 is safe with heat sources. Individual #3's individual support plan, last updated 3/25/2025, documents Individual #3 needs to be monitored around heat sources. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The CPS Program Director educated and trained Program Specialist on 2380.182 regulations. Individual #3¿s Support Coordinator will be contacted and informed that when #3 `s initial and annual functional were completed, PTA noted that #3 can ¿sense heat and move form it quickly¿ and are asking that the ISP be updated. This letter;/email will be attached to #3¿s ISP and functional. |
04/25/2025
| Implemented |