| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(d) | The evacuation time for the fire drill held on 8/25/23 was 2 minutes and 52 seconds. This was the only fire drill completed in August 2023. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | Fire Safety Expert was emailed on 09/25/2023 to request an evacuation time extension for this location. This request was granted on 09/25/2023 and the evacuation time for this location has been extended to 3.5 minutes (Attachment #1). Additionally, per the fire safety expert's recommendation, a training specific to Individual #2 was created on 09/25/2023 (Attachment #5). |
09/25/2023
| Implemented |
| 2380.181(e)(14) | The current assessment for individual #1, dated 7/5/23, does not address the individual's ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | On 09/22/2023, Individual #1's assessment was updated to include their ability to swim and knowledge of water safety. The assessment update was reviewed with and signed by Individual #1 and Staff #2 (Attachment #2). A copy of the assessment update was emailed to the Supports Coordinator on 09/25/2023 and a copy was emailed to Individual #1's home on 09/25/2023. |
09/25/2023
| Implemented |
| 2380.21(r) | The signed individual rights document for individual #1, dated 5/30/23, and individual #2 , dated 12/5/22, does not address that an individual's rights shall be exercised so that another individual's rights are not violated. | An individual's rights shall be exercised so that another individual's rights are not violated. | On 09/20/2023, an updated Individual Rights was created and disbursed to all CARES of Central PA Day Program Specialists. The new Individual Rights was reviewed with and signed by Individual #1(Attachment #4) and Individual #2 (Attachment #3) on 09/21/2023. All other currently enrolled individuals are currently reviewing and signing the updated Individual Rights as well. |
09/25/2023
| Implemented |
| 2380.21(s) | The signed individual rights document for individual #1, dated 5/30/23, and individual #2, dated 12/5/22, does not address that the facility shall assist the affected individuals to negotiate choices in accordance with the facility's procedures for the individuals to resolve differences. | The facility shall assist the affected individuals to negotiate choices in accordance with the facility's procedures for the individuals to resolve differences and make choices. | On 09/20/2023, an updated Individual Rights was created and disbursed to all CARES of Central PA Day Program Specialists. The new Individual Rights was reviewed with and signed by Individual #1(Attachment #4) and Individual #2 (Attachment #3) on 09/21/2023. All other currently enrolled individuals are currently reviewing and signing the updated Individual Rights as well. |
09/25/2023
| Implemented |
| 2380.21(t) | The signed individual rights document for individual #1 dated 5/30/23, and individual #2, dated 12/5/22, does not include that rights can only be modified in accordance with § 2380.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | An individual's rights may only be modified in accordance with § 2380.185 (RELATING TO CONTENT OF THE INDIVIDUAL PLAN) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | On 09/20/2023, an updated Individual Rights was created and disbursed to all CARES of Central PA Day Program Program Specialists. The new Individual Rights was reviewed with and signed by Individual #1(Attachment #4) and Individual #2 (Attachment #3) on 09/21/2023. All other currently enrolled individuals are currently reviewing and signing the updated Individual Rights as well. |
09/25/2023
| Implemented |