| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | At the time of inspection, the home's trashcan was overfilled with bags of trash such that the hinged lid of the trashcan was propped open approximately 16 inches, exposing the contents of the trashcan. This trash was not protected from penetration by insects and rodents | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The organization will purchase an additional trashcan from the Township and agree to the additional monthly expense to ensure that there is enough space to prevent overflowing. |
10/21/2024
| Implemented |
| 6400.144 | Individual #1 is prescribed the following two Pro re Nata (PRN) medications: Sudafed PE and Eucerin Original Healing Cream. At the time of inspection, neither of these medications could be located within the home. As these medications were not kept on-hand to administer as instructed PRN, pharmaceutical services prescribed for the individual were not arranged for the individual by the provider. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Our Nursing Team has updated the OTC sheet to ensure that medications' ingredients match what is listed on the OTC sheet. Both medications have been purchased and placed in the program. |
10/14/2024
| Implemented |
| 6400.181(e)(14) | Individual #1's most recent Individual Assessment, dated 04/18/2024, does not note the individual's ability to swim. This area of the assessment contained an item that read, "Ability to swim (can propel self through water)" and was answered with "Not Applicable." As this answer reads, it appears that the item was skipped by the Program Specialist completing the assessment. If the individual's ability to swim has not or cannot be assessed, this should be clearly and unambiguously noted by the Program Specialist. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The Individual Assessment has been corrected. It now clearly lists the individual's ability to swim. |
10/07/2024
| Implemented |
| 6400.213(1)(i) | § 6400.213(iv). Individual #1's Individual Record did not contain the individual's Religious Affiliation | Each individual's record must include the following information : The religious affiliation. | Individual's religious affiliation has been added to their Individual Record. |
10/07/2024
| Implemented |