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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(a) | Individual #1, date of admission 7/23/2024, had his initial assessment completed on 10/22/2024. | 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. | On 3/25/25, the Vice President of Residential and Disability Services retrained the Residential Directors and Program Specialists on regulation 6400.181(a). |
03/25/2025
| Implemented |
| 6400.165(d) | On 3/12/2025 at approximately 9:10am the following pro re nata medications prescribed to Individual #1 were labeled as "House stock medications": Ibuprofen tab 200mg, Guaiasorb DM Liq. 325MG, Acetaminophen tab 325MG, Aloe Ver Gel, Loratadine Tabs 10mg, Bismatrol suspension 525MG/300ML, A&D Ointment, Hydrocort Cre 1%, Anti-diarrhea sol 1mg/7.5, Antacid sus reg st. The house stock prescription medications were to be utilized by any individual in the home with a current order for said medication. Additionally, the pharmacy issued medication label did not include administration instructions such as the individual's name, medication dosage, administration route, or frequency of administration. | A prescription medication shall be used only by the individual for whom the prescription was prescribed. | On 3/13/25, the Vice President of Residential and Disability Services retrained the Nurses on regulation 6400.165(d). Medication labels will be completed by 5/16/25. |
05/16/2025
| Implemented |
| 6400.207(5)(III) | On 3/13/2025 at 11:09am, Individual #2's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for full bed rails on 6/23/23. Although the bed rails are prescribed by the medical practitioner, the most current assessment dated 6/24/2024 does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's individual plan last updated 10/29/2024 does not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | On 3/25/25, the Vice President of Residential and Disability Services retrained the Program Specialists to include documentation of regulation 6400.207(5)(iii) in the annual assessment, along with a physician's order. |
03/25/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The written emergency evacuation procedures do not inclued the means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Quality Assurance Director revised the Emergency Evacuation Plan on 12/24/14 to include that the means of transportation will be by Agency and Staff vehicles and that the emergency shelter location are the Avalon Hotel on 16 West 10th Street, Erie, PA 16501, client family member's, or staff member's homes. The revised Emergency Evacuation Plan will be distributed to all group homes by january 1, 2015. |
12/29/2014
| Implemented |
| 6400.106 | The furnace has not been inspected and cleaned for several years by a professional furnace cleaning company or trained staff person. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Maintenance Manager will schedule the furnace cleaning and inspection with a professional cleaning company by January 16, 2015. The Maintenance Manager will schedule the cleaning and inspections to be done by a professional cleaning company annually. The Program Specialist will receive a copy of the cleaning and inspection reports to ensure they were done by the professionally cleaning company annually. |
12/29/2014
| Implemented |
| 6400.112(c) | The fire drill record for the fire drill conducted on 7/26/14 does not include the exit route used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Fire Drill Form had an identified space to document the exit route, but staff failed to document the exit route on the form for the 7/26/2014 fire drill. The Fire Drill Report Form Does not need to be revised to include "exit route". The Program Specialist retrained the staff members who conduct the fire Drills on how to complete the Fire Drill Report Form accurately and thoroughly on 12/22/14. All Program Specialists will review all completed Fire Drill Report Forms in their assigned houses to ensure they are completed thoroughly and accurately. The Senior Community Home Coordinator will conduct random reviews of the Fire Drill Report forms to ensure they are completed accurately and thoroughly. |
12/29/2014
| Implemented |
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