| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.143(a) | Individual #1 has a documented refusal for a physical examination; however, the refusal form indicated "8/8" and did not include the year, therefore compliance could not be measured. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Program Specialists will review medical appointment paperwork weekly to ensure all supporting documentation is accurately completed and attached. They will communicate with house supervisors and staff if they discover missing documentation so it can be added to the medical records. Program supervisors review person centered practices for educating an individual on the importance of health care with program staff. Review of PCP includes how to properly document refusals and on-going education. [Documentation of training, dated 10/12/22 and 10/13/22, related to medical appointment refusals, to include documentation of refusals and rescheduling a refused appointment, was received on 2/15/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/2023]. |
10/03/2022
| Implemented |
| 6400.51(b)(5) | Program Specialist #2, date of hire 8/8/2022, did not complete the following orientation topic within 30-days after hire: Job-related knowledge and skills. This would include training on implementation of the individual plans and the appropriate use of behavior supports. | The orientation must encompass the following areas: Job-related knowledge and skills. | The Director of Quality worked with Human Resources to assign required orientation trainings with due dates to program staff in the agency's learning management system. Program supervisors review staff training completion and compliance monthly and follow-up with staff who haven't completed trainings as assigned. [Documentation of monthly review of staff training, dated 1/25/23, was received on 2/15/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.52(c)(1) | Chief Executive Officer #1, date of hire 11/12/2018, did not complete the following training topic for the annual training year 7/1/21 to 6/30/22: the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | 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. | The Director of Quality assigned required annual trainings with due dates to all administrative staff, including the CEO, in the agency's learning management system. The Director of Quality sends staff training completion and compliance reports monthly and follows-up with staff who haven't completed trainings as assigned. [Documentation of monthly review of staff training, dated 1/25/23, was received on 2/15/23 and reviewed 3/1/23. Documentation of the annual training plan that includes "Building Relationships and Community Membership," dated as completed on 9/29/22, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/2023]. |
10/03/2022
| Implemented |
| 6400.52(c)(2) | Chief Executive Officer #1, date of hire 11/12/2018, did not complete the following training topic for the annual training year 7/1/21 to 6/30/22: the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adult Protective Services Act, the Child Protective Service Law, the Adult Protective Services Act, and applicable adult protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The Director of Quality assigned required annual trainings with due dates to all administrative staff, including the CEO, in the agency's learning management system. The Director of Quality sends staff training completion and compliance reports monthly and follows-up with staff who haven't completed trainings as assigned. [Documentation of monthly review of staff training, dated 1/25/23, was received on 2/15/23 and reviewed 3/1/23. Documentation of the annual training plan that includes training topics related to the prevention, detection, and reporting of abuse was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |
| 6400.52(c)(3) | Chief Executive Officer #1, date of hire 11/12/2018, did not complete the following training topic for the annual training year 7/1/21 to 6/30/22: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The Director of Quality assigned required annual trainings with due dates to all administrative staff, including the CEO, in the agency's learning management system. The Director of Quality sends staff training completion and compliance reports monthly and follows-up with staff who haven't completed trainings as assigned. [Documentation of monthly review of staff training, dated 1/25/23, was received on 2/15/23 and reviewed 3/1/23. Documentation of the annual training plan that includes Individual Rights, dated as completed on 10/20/22, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/2023]. |
10/03/2022
| Implemented |
| 6400.52(c)(4) | Chief Executive Officer #1, date of hire 11/12/2018, did not complete the following training topic for the annual training year 7/1/21 to 6/30/22: Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The Director of Quality assigned required annual trainings with due dates to all administrative staff, including the CEO, in the agency's learning management system. The Director of Quality sends staff training completion and compliance reports monthly and follows-up with staff who haven't completed trainings as assigned. [Documentation of monthly review of staff training, dated 1/25/23, was received on 2/15/23 and reviewed 3/1/23. Documentation of the annual training plan that includes Recognizing and Reporting Incidents, dated as completed on 11/25/22, was received on 2/15/23 and reviewed 3/8/23. DPOC by HDKP, HSLS, on 3/8/23]. |
10/03/2022
| Implemented |