| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | On 1/5/23 at 9:35AM, there were two outdoor trash receptacles in the front of the home overflowing with trash in bags causing the lids not to fully close. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | An additional outdoor trash receptacle with closing lid was purchased for the Smithton home to ensure that there are no occasions in which the lid is not able to close completely. Each site was contacted on 1/12/2023 to ensure that there are no occasions in which their trash receptacle could not close due to excessive amounts of garbage or other related issues. It was confirmed that all other community living arrangements have trash receptacles that are large enough to accommodate the amount of trash that they produce. |
01/12/2023
| Implemented |
| 6400.141(c)(9) | Individual #1, date of birth 2/19/58, who was admitted on 2/12/85, had a prostate examination on 7/27/22. There was not a record of the previous prostate examination; therefore, compliance could not be measured. | The physical examination shall include: A prostate examination for men 40 years of age or older. | A tracking spreadsheet for medical exams was created on 1/30/2023, and includes tracking the dates of each individual's prostate exam to allow the program specialist to monitor the completion of a prostate exam. |
01/30/2023
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination on 3/15/19 and then again 1/3/22. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | A tracking spreadsheet for medical exams was created on 1/30/2023, and includes tracking the dates of each individual's dental exam to allow the program specialist to monitor the completion of a dental exam. |
01/30/2023
| Implemented |
| 6400.171 | On 1/5/23 at 10:08AM, there was a small block of cheese with what appears to be mold and a package of partially used "deli" meat with a best use by date of 10/1/22 in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| A checklist of duties for overnight or other designated staff was created on 1/31/2023. Site monitors and program specialist will be trained on the proper completion of the checklist during a meeting scheduled for 2/17/2023. This checklist includes checking the refrigerator for expired or unlabeled food. |
02/17/2023
| Implemented |
| 6400.15(b) | The agency used a Department's licensing inspection instrument modified in June 2018. The current licensing inspection summary instrument for the community homes for individuals with intellectual disability or autism regulations was promulgated in February 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The internal policy for self-assessment was updated on 1/25/2023 to include the current Provider self-assessment tool, and previously used forms were replaced on the shared drive with the correct form on the same date. The form was forwarded via email to the Chief Executive Officer and Program Specialist on 1/6/2023 with direction that this form should be utilized moving forward per inspection. |
01/25/2023
| Implemented |
| 6400.20(b) | The home is not reviewing and analyzing incidents and conducting and documenting a trend analysis for at least the prior year. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | The agency will implement the use of an incident review committee consisting of a minimum of two members of the management team. The incident review committee will complete and document trend analysis for incidents occurring in each residential home individually and across the board. Documentation of data and trend analysis will be kept by an employee qualifying as program specialist. The first committee meeting will occur on February 17, 2023. |
02/17/2023
| Implemented |
| 6400.34(b) | Individual #1 signed a statement acknowledging receipt of the information on individual rights on 1/1/20 then again 1/1/22. | 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. | Program Specialists will continue with its current process of having the individual rights page reviewed and signed by all individuals served in the community living arrangements on January 1st of each calendar year. However, should an individual plan to not be in the care of the program during this time (January 1st) an individual rights form will be reviewed and signed by the individual or the individual¿s court appointed guardian prior to their departure. A training of regulatory standards for individual rights documentation will be completed with site monitors and program specialist in February 17, 2023. |
02/17/2023
| Implemented |
| 6400.52(b)(1) | Chief Executive Officer #1 completed 7.5 hours of annual training in the training year from January 1, 2022 to December 31, 2022. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | A tracking spreadsheet was created on 1/31/2023 to monitor the Chief Executive Officer¿s training hours and added to the shared folder where tracking spreadsheets for monitoring the training hours of program specialists and direct support staff are saved. The Chief Executive Officer will schedule and complete 12 hours of training per calendar year. The next measurement period is January 1, 2023 ¿ December 31, 2023. |
01/31/2023
| Implemented |
| 6400.52(c)(1) | Chief Executive Officer #1's training for the training year from January 1, 2022 to December 31, 2022, did not include 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 Chief Executive Officer will attend the online, self-paced Person Centered Practices training provided by the Office of Developmental Programs by February 28, 2023. Completion of this training will be evidenced by retention of a training certificate. A tracking spreadsheet was created on 1/31/2023 to monitor the Chief Executive Officer¿s training hours and added to the shared folder where tracking spreadsheets for monitoring the training hours of program specialists and direct support staff are saved. |
02/28/2023
| Implemented |
| 6400.52(c)(2) | Chief Executive Officer #1's training for the training year from January 1, 2022 to December 31, 2022, did not include the prevention, detection, and reporting of abuse, and alleged abuse. | 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 Chief Executive Officer will attend the online, self-paced Abuse: Detection, Reporting, and Prevention of Abuse and Alleged Abuse training provided by the Office of Developmental Programs by February 28, 2023. Completion of this training will be evidenced by retention of a training certificate. A tracking spreadsheet was created on 1/31/2023 to monitor the Chief Executive Officer¿s training hours and added to the shared folder where tracking spreadsheets for monitoring the training hours of program specialists and direct support staff are saved. |
02/28/2023
| Implemented |
| 6400.52(c)(3) | Chief Executive Officer #1's training for the training year from January 1, 2022 to December 31, 2022, did not include Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The Chief Executive Officer will attend the online, self-paced Individual Rights training provided by the Office of Developmental Programs by February 28, 2023. Completion of this training will be evidenced by retention of a training certificate. A tracking spreadsheet was created on 1/31/2023 to monitor the Chief Executive Officer¿s training hours and added to the shared folder where tracking spreadsheets for monitoring the training hours of program specialists and direct support staff are saved. |
02/28/2023
| Implemented |
| 6400.52(c)(4) | Chief Executive Officer #1's training for the training year from January 1, 2022 to December 31, 2022, did not include Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The Chief Executive Officer will attend the online, self-paced Recognizing and Reporting Incidents training provided by the Office of Developmental Programs by February 28, 2023. Completion of this training will be evidenced by retention of a training certificate. A tracking spreadsheet was created on 1/31/2023 to monitor the Chief Executive Officer¿s training hours and added to the shared folder where tracking spreadsheets for monitoring the training hours of program specialists and direct support staff are saved. |
02/28/2023
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Refresh Celluvisc Op 1%, instill one drop into both eyes 6 times daily. Individual #1's January 2023 Medication Administration Record for this medication had Refresh Tears 0.5% Eye drop apply 1 drop to eye 6 times per day. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | A checklist of weekly duties for overnight or other designated staff was created on 1/31/2023. Site monitors and program specialist will be trained on the proper completion of the checklist during a meeting scheduled for 2/17/2023. This checklist includes ensuring that all medication labels match the MAR and include the medication strength. A training on regulatory standards for medication will be completed with site monitors and program specialist in a meeting scheduled for 2/17/2023. |
02/17/2023
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Refresh Celluvisc Op 1%, instill one drop into both eyes 6 times daily. Individual #1's January 2023 Medication Administration Record reads Refresh Tears 0.5% Eye drop, apply 1 drop to eye 6 times per day. The medication administration record does not indicate to apply to both eyes. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | A checklist of weekly duties for overnight or other designated staff was created on 1/31/2023. Site monitors and program specialist will be trained on the proper completion of the checklist during a meeting scheduled for 2/17/2023. This checklist includes ensuring that all medication labels match the MAR and include the medication strength. A training on regulatory standards for medication will be completed with site monitors and program specialist in a meeting scheduled for 2/17/2023. |
02/17/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's January 2023 Medication Administration Record does not include the diagnosis or purpose for Refresh Celluvisc Op 1% eye drops. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Upon receipt of a new medication and/or MAR the site monitor or on site employee is responsible for ensuring that the medication label includes all required items and matches the MAR. In order to ensure this step is being completed, a checklist of weekly duties for overnight or other designated staff was created on 1/31/2023. Site monitors and program specialist will be trained on the proper completion of the checklist during a meeting scheduled for 2/17/2023. This checklist includes ensuring that all medication labels match the MAR and include the medication purpose. A training on regulatory standards for medication will be completed with site monitors and program specialist in a meeting scheduled for 2/17/2023. |
02/17/2023
| Implemented |