| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.61(a) | 1.Six DSPs are utilized: two in the morning, two in the evening, and two at night. Neither the apartment nor the building is equipped for handicapped access. The DSPs are carrying individual #1 up and down the stairwells, which presents a serious safety concern. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | Individual is able to ambulate to some degree. Although it is not a safe situation for her to navigate steps her staff can help her to get up and down the steps. They are not physically carrying her up and down the stairs. I'm not sure where this information was gathered but the individual is over 250lbs and 6"2 none of the ladies who work with her are physically able to lift her. One staff member is behind her and the other in front when going up and down the stairs currently. |
06/07/2024
| Implemented |
| 6400.68(b) | The water temperature in the bathroom measured at 126°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Individual is able to temper water appropriately and understands how to regulate hot and cold water. This information is her isp and current residential assessment. |
06/05/2024
| Implemented |
| 6400.70 | The telephone in the home was not operable. Staff attempted to connect and made attempts to get the phone to work but were not able to do so during the inspection. The individual living in the home did not have access to a working home telephone and staff were utilizing their cell phones for communication. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| There was an operating phone present at the time of inspection. The staff had it unplugged. The phone is plugged back into the proper outlets and is operable. |
06/04/2024
| Implemented |
| 6400.112(d) | The fire drill documentation incorrectly records verbal prompting; it should also include physical prompting/assistance, as Individual #1 cannot mentally process such prompts and is non-ambulatory. Individual #1 experiences severe auditory hallucinations and uses a walker. For compliance, the documentation must align with Individual #1's ISP and diagnosis, supporting the need for physical assistance. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | These were documentation errors on behalf of the staff on shift at the time of the fire drill. All staff who work with the individual know they must physically assist the individual during evacuation; she wouldn't be able to evacuate without that assistance from staff. The documentation errors were corrected by staff. |
06/04/2024
| Implemented |
| 6400.32(d) | Individual #1 is not receiving dignified and respectful treatment as she cannot enter or exit her home without being carried by staff. The bathroom in the apartment is too small to fit the individual and their walker, and there is minimal space for staff to assist with ADLs. | An individual shall be treated with dignity and respect. | A new home has been identified for the individual. Address is Blair Mill Road, APT I-1 Building C, Willow Grove PA,19090. We are planning to have a tour of this apartment with her plan team on 6/11/24. If all goes well with the tour we will move forward with the licensing process and hopefully have ES in her new apartment by 7/1/24. |
06/05/2024
| Implemented |
| 6400.32(n) | As there is no working telephone, the individual doesn't have unrestricted and private access to telecommunications. | An individual has the right to unrestricted and private access to telecommunications. | There was an operating phone present at the time of inspection. The staff had it unplugged. The phone is plugged back into the proper outlets and is operable. |
06/04/2024
| Implemented |
| 6400.34(a) | No proof that individual rights were reviewed, the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter was given at the time of the inspection. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual reviewed her individual rights with her PS annually. Her last review of her rights was completed on 9/23/23. Attached is documentation. We keep all consents and other documents signed by the participants in their program binders at our main office. They are scanned into the individuals folder in google cloud. Staff have access to these files and can give the individual access as well as each site has an operable computer. |
06/04/2024
| Implemented |
| 6400.34(b) | No documentation that the individual acknowledged receipt of the information on individual rights was provided. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | Individual reviewed her individual rights with her PS annually. Her last review of her rights was completed on 9/23/23. Attached is documentation. We keep all consents and other documents signed by the participants in their program binders at our main office. They are scanned into the individuals folder in google cloud. Staff have access to these files and can give the individual access as well as each site has an operable computer. |
06/04/2024
| Implemented |