| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.14(b) | An initial issuance of the fire safety occupancy permit by the Department of Labor and Industry was completed as required but verification annually in writing by the provider, that the permit for the facility has not been withdrawn was not completed as required. | After initial issuance of the fire safety occupancy permit by the Department of Labor and Industry, the provider shall verify, annually in writing, that the permit for the facility has not been withdrawn. | A letter verifying that the occupancy permit is in good standing and has not been withdrawn has been created. |
06/10/2025
| Implemented |
| 2390.53 | The rear exit was used as egress and walkway to the meeting place in the alley for most fire drills from 5/2024 to 5/2025. This exit of the building enters into a vacant lot that is littered with debris such as scattered objects, broken concrete of varying size, broken bottles, shattered glass, remains of foundations from buildings, a large white pipe sticking out of the ground approximately two feet and uneven surfaces. Individual #1 participated in the monthly fire drills and is legally blind, using a cane for the visually impaired to navigate the community. The absence of an obstacle free path to the fire drill meeting places presented great potential hazards.
The wooden ramp leading from the rear exit and into the lot and alley presented additional hazards. The skid strips on the boards of the ramp where buckled and peeling in several spots. One board close to the bottom of the ramp was rotted and missing wood to an approximate depth of one inch across the center two thirds of the board. The first board from the deck leading down the ramp was raised to a height of approximately one inch at the left corner. The height difference between the board and the deck became greater when stepping on the deck as the deck bowed. The ramp presented with multiple areas that created a tripping hazard and appeared to be structurally unsound. | Outside walkways shall be free from ice, snow, leaves, equipment and other hazards. | A work order has been completed to replace the rotting boards on the ramp, and to replace the treads on the ramp. A quote was acquired for stone to level out the area behind the building where the rear emergency evacuation route is located. |
06/10/2025
| Implemented |
| 2390.61 | The wall above the right entrance to the lunchroom showed evidence of what appeared to be water damage and streaks. The area above the open archway was crumbling, leaving a small hole under the strobe light. The top of the archway had similar evidence of water damage and peeling paint.
The metal back door had what appeared to be rust approximately six inches up the side of the door with the same area being broken open. The metal door frame had what appeared to be rust to a height of approximately six inches on each side. Portions of the bottom of the metal door frame on both sides were missing and appeared to have rusted away. | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. | A work order was completed to repair the water damage and crumbling to the wall.
Contact was made with a local door company, Muncy Door, to replace the metal door and frame. We are currently waiting for the quote for the replacement door and frame. |
06/10/2025
| Implemented |
| 2390.85(b) | The hypothetical location for the fire drills was not different for each drill as required. Drills completed on 8/30/24 and 3/31/25 used the hypothetical location "lunchroom" for both drills. Drills completed on 7/30/24 and 4/28/25 used the hypothetical location "register" for both drills. Drills completed on 5/8/24 and 12/30/24 used the hypothetical lo\cation of "office" and "office area" for both drills. | Fire drills shall be held at different times of the day. Hypothetical locations of the fire shall be different for each drill. | Fire Drill protocol was reviewed with program staff, and they were reminded that hypothetical fire locations need to rotate monthly. The lead program specialist will track the locations of the hypothetical fires to ensure that different locations are being used. |
06/10/2025
| Implemented |
| 2390.151(e)(13(ii) | The assessment dated 3/6/25 for Individual #1 was the provider created format dated 1/2014. A section assigned to the communication of their wants and needs was present but did not address any progress or lack there of over the last 365 days. A section to address motor skills was present but did not address any progress or lack thereof over the last 365 days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The assessment for individual #1 has been updated to include the individual's progress over the last 365 calendar days and current level in the area of motor and communication skills. |
06/10/2025
| Implemented |
| 2390.151(e)(13)(iii) | The assessment dated 3/6/25 for Individual #1 was the provider created format dated 1/2014. A section assigned for the assessment of personal adjustment was present but did not include any progress or lack thereof over the last 365 days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The assessment for individual #1 has been updated to include the individual's progress over the last 365 calendar days and current level in the area of personal adjustment. |
06/10/2025
| Implemented |
| 2390.151(e)(13(iv) | The assessment dated 3/6/25 for Individual #1 was the provider created format dated 1/2014. A section assigned for the assessment of the Individuals ability to interact with peers did not any progress or lack thereof over the last 365 days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The assessment for individual #1 has been updated to include the individual's progress over the last 365 calendar days and current level in the area of socialization. |
06/10/2025
| Implemented |
| 2390.49(c)(6) | There was no documentation to illustrate that Staff #1 had training on the Individual Support Plan for Individual #1 or Individual #2 as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with a client. | Staff #1 has completed the ISP reviews for Individual #1 and Individual #2. Staff #1 is the new program specialist for the program. Her caseload had just changed to include the individuals in the program. |
06/10/2025
| Implemented |