| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency completed a self-assessment from 3/1/2024 through 3/25/2024, and documented the following violations, 6400.18g, 6400.18i, 6400.45e. A written summary of corrections was not kept by the agency. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on the self-assessment process including the assessment window and documentation process of corrections by September 30th, 2024. Training forms will be provided as documentation (Attachments Training A). |
09/30/2024
| Implemented |
| 6400.63(a) | At 1:03PM on 8/1/2024, a "Infrared Dr. Heater" with "Bed Bug Toaster" that heats up to 150°F was unlocked and accessible in the attached garage of the home. Individual #1's Service Plan, last updated 7/9/2024, reads, "[Individual #1] IS AWARE OF THE DANGERS OF HEAT SOURCES, ELECTRICAL OUTLETS AND KNIVES; HOWEVER, [Individual #1] MAY NOT HANDLE THEM SAFELY OR USE PROPER PRECAUTIONS WHEN NEAR THEM." | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Immediately following the licensing visit, a maintenance request was entered on 8/1/24 (Attachment Document 2) to have the "Bed Bug Toaster" removed from the home. The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on regulation 6400.63 by September 30th, 2024. Training forms will be provided as documentation (Attachment Training G). A memo outlining the regulation and expectations will be written and given to the maintenance department (Attachment Document 1). |
09/30/2024
| Implemented |
| 6400.64(b) | At 1:02PM on 8/1/2024, there was an inordinate amount of deceased and live flies on the window sill, floor and refrigerator in the garage of the home. | There may not be evidence of infestation of insects or rodents in the home. | Immediately following the licensing visit, a maintenance request was entered on 8/1/24 (Attachment Document 3) to have all insects removed from the home. The home has been cleaned, and all insects have been removed. The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on regulation 6400.64 by September 30th, 2024. Training forms will be provided as documentation (Attachment Training H). |
09/30/2024
| Implemented |
| 6400.110(b) | The closest smoke detector is nineteen feet and eight inches away from Individual #1's bedroom. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | A smoke detector was immediately installed after licensing. (Attachment) |
09/30/2024
| Implemented |
| 6400.113(a) | Individual #1, date of admission 5/1/2023, was initially trained in fire safety on 10/25/2023. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Upon further review, documentation was located that showed Fire Safety Training was completed on 5/1/2023 (Attachment Document 15). The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on annual plan requirements for admissions and annually. Training forms will be provided as documentation (Attachment Training O). |
09/30/2024
| Implemented |
| 6400.143(a) | Individual #1 refused to attend a scheduled psychiatric medication review appointment on 5/22/2024. There was no documentation of any attempts to train the individual about the need for health care. | 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. | The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on Refusal Plans by September 30th, 2024. Training forms will be provided as documentation (Attachment Training S). |
09/30/2024
| Implemented |
| 6400.144 | Individual #1 has a bedrail attached to her bed. The bedrail appears to be stabilized by throw pillow(s) between the bedrail and the mattress. There are no physician's orders for the bedrails. | 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.
| A new bed was purchased for the person supported. (Attachment) |
09/30/2024
| Implemented |
| 6400.181(a) | Individual #1's assessment was completed 6/5/2023 and then again on 7/12/2024. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Program Director, Program Manager, Program Specialist, and Program Supervisors will be retrained by the Assistant Executive Director on the regulation requirements of 6400.181 by September 30th, 2024. Training forms will be provided as documentation (Attachment Training V). |
09/30/2024
| Implemented |
| 6400.32(h) | At 1:00PM on 8/1/2024, there were cameras throughout the common areas of the home. Staff interviews revealed that the footage is saved for thirty days and then deleted. There was a monitor in the staff office that showed a live feed of all common areas. | An individual has the right to privacy of person and possessions. | All camera monitors that are stationary in the home will be removed and not be in the common areas displaying live footage. An IT ticket will be submitted for all monitors to be removed. |
09/30/2024
| Implemented |
| 6400.46(a) | Program Specialist #1, date of hire 4/22/2024, has not completed training in fire safety. Direct Service Worker #2, date of hire 11/19/2023, was trained in fire safety on 9/26/2023; however, the training did not include information relating to evacuation procedures and designated meeting place. [Repeat Violation, 8/23/2024] | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Program Specialist #1 completed Fire Safety Training on 8/27/2024, and Direct Service Worker # 2 completed Fire Safety Training on 8/27/24 (Attachment Document 16). The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on staff training requirements. Training forms will be provided as documentation (Attachment Training T). |
09/30/2024
| Implemented |
| 6400.51(b)(1) | Program Specialist #1, date of hire 4/22/2024, did not complete orientation training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Program Specialist completed person-centered practices on 8/7/2024, Acknowledging self determination 0n 9/5/2024, Community Participation supports on 8/20/24, and Budling Relationships on 9/5/2024. |
09/30/2024
| Implemented |
| 6400.51(b)(2) | Program Specialist #1, date of hire 4/22/2024, did not complete orientation training on 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 orientation 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. | Program Specialist #1 completed training on recognizing and reporting emergencies on 9/4/2024(Attachment Document 21). The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on staff training requirements. Training forms will be provided as documentation (Attachment Training T). |
09/30/2024
| Implemented |
| 6400.51(b)(3) | Program Specialist #1, date of hire 4/22/2024, did not complete orientation training on individual rights. | The orientation must encompass the following areas: Individual rights. | Program Specialist #1 completed training on individual rights on 8/2/2024 (Attachment Document 20). The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on staff training requirements. Training forms will be provided as documentation (Attachment Training T). |
09/30/2024
| Implemented |
| 6400.51(b)(4) | Program Specialist #1, date of hire 4/22/2024, did not complete orientation training on recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | Program Specialist #1 completed training on recognizing and reporting emergencies on 8/9/2024 (Attachment Document 21). The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on staff training requirements. Training forms will be provided as documentation (Attachment Training T). |
09/30/2024
| Implemented |
| 6400.51(b)(5) | Program Specialist #1, date of hire 4/22/2024, did not complete orientation training on job related knowledge and skills. | The orientation must encompass the following areas: Job-related knowledge and skills. | Program Specialist #1 will complete training on job related knowledge and skills 9/30/24 (Attachment Document 22). The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on staff training requirements. Training forms will be provided as documentation (Attachment Training T). |
09/30/2024
| Implemented |
| 6400.163(h) | Individual #1 was previously prescribed Ozempic injections with instructions to, "inject .5mg under the skin every seven days for Diabetes." The medication dosage was changed from .5mg to .25mg on 6/27/2024 and the previous medication was not discarded. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The medication was immediately discarded following the licensing visit. The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on auditing MARs and medication, including disposals by September 13th, 2024. Training forms will be provided as documentation (Attachment Training Q). |
09/30/2024
| Implemented |
| 6400.165(b) | Individual #1 is prescribed Ozempic injections with instructions to, "inject .25mg under the skin every seven days for Diabetes." The medication dosage was changed from .5mg to .25mg on 6/27/2024 and Individual #1's Medication Administration Record documents a .5mg dose administered on 6/29/2024. | A prescription order shall be kept current. | The medication was immediately discarded following the licensing visit. The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on auditing MARs and medication, including disposals by September 30th, 2024. Training forms will be provided as documentation (Attachment Training Q). |
09/30/2024
| Implemented |
| 6400.167(a)(3) | Individual #1 is prescribed Ozempic injections with instructions to, "inject .25mg under the skin every seven days for Diabetes." The medication dosage was changed from .5mg to .25mg on 6/27/2024 and Individual #1's Medication Administration Record documents a .5mg dose administered on 6/29/2024. | Medication errors include the following: Administration of the wrong dose of medication. | An EIM was entered immediately following licensing. The provider staff was retrained immediately (Attachment Med Error Training 1). The medication that was discontinued was immediately discarded. The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on auditing MARs for accuracy by September 13th, 2024. Training forms will be provided as documentation (Attachment Training Q). |
09/30/2024
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment to the plan team members for the Individual plan meeting on 10/4/2023. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Director, Program Manager, Program Specialist, and Program Supervisors will be retrained by the Assistant Executive Director on the regulation requirements of 6400.181 by September 30th, 2024. Training forms will be provided as documentation (Attachments Training V). |
09/30/2024
| Implemented |