| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 6/06/21 to 9/06/21, and the self- assessment was dated 3/17/22. This exceeds the requirement. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Training will be completed with Program Specialists by 5/20/2022 regarding 55 PA Code Chapter 6400.15 (a) by having self assessments completed 3-6 months prior to expiration of certification. Attachement #3 is the completed Self assessment that was completed in the 3-6 month timeframe in 2021. |
05/20/2022
| Implemented |
| 6400.67(a) | Two of Individual #1's bedroom windows had what appeared to be gray weather seal that was hanging down from her window that ranged from 3 to 9 inches. Three of the bedroom windows in Individual #2's bedroom windows had what appeared to be gray weather seal that was hanging down from her window that ranged from 2 to 8 inches. In the hallway outside of Individual #1's bedroom on the ceiling approximately 12 inches long the paint was peeling and missing from the ceiling. The paint on the bilco doors in the basement were peeling in numerous areas, and they were covered in brown rust like color. The front wooden door of the home had approximately 6 areas ranging in ½ to 2-inch holes exposing sunlight and breeze into the home. Surfaces shall be in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | Individual #1's bedroom window has been repaired on 5/9/2022 (Attachment #4), Individual #2 bedroom window has been repaired on 5/9/2022 (Attachment #4a), Peeling and missing paint from the ceiling has been repainted on 5/10/2022 (Attachment #4b), bilco doors in the basement will be resolved with the peeling paint and rust areas by 5/13/2022 (Attachment #4c), and the front door has been repaired on 5/12/2022 (Attachment #4d) |
05/13/2022
| Implemented |
| 6400.77(b) | The first aid kit did not contain an assortment of adhesive bandages | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Assortment of adhesive bandages were placed in the first aid kit on 4/6/2022. First aid Check list will be completed on a monthly basis. Attachment #5, #5a |
04/06/2022
| Implemented |
| 6400.77(c) | The home did not have a fist aid manual with the first aid kit. | A first aid manual shall be kept with the first aid kit. | First aid manual was placed in the first aid kit on 4/6/2022. First aid Check list will be completed on a monthly basis. Attachment #5, #5a |
04/06/2022
| Implemented |
| 6400.82(f) | The bathroom located in Individuals #1's bedroom did not contain soap at the time of the inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Training will be completed with Program Specialists by 5/20/2022 regarding what items are to be in the bathrooms at all times in regards to the 55 PA Code Chapter 6400.82 (f) Soap was placed in the bathroom on 4/6/2022. Attachment # 6 |
05/20/2022
| Implemented |
| 6400.141(c)(8) | Individual #1 had a mammogram completed on 1/27/20 and her next one was completed on 4/23/21. This exceeds the requirement. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Training will be completed with Program Specialists by 5/20/2022 regarding proper documentation on a physical and medical forms and to ensure that all medical appointments are in compiance with the doctors orders. Attachment #7 |
05/20/2022
| Implemented |
| 6400.144 | Individual #1 wears glasses and had an annual vision exam on 1/6/21 and their next exam was completed on 3/9/22. Individual #1 had a mammogram completed on 1/27/20 and her next one was completed on 4/23/21. Health Services are not being provided by the agency. | 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.
| Individual #1 next eye appointment is scheduled for 3/9/2023. Training will be completed with Program Specialist on proper documentation on a physical and medical forms and to ensure that all medical appointments are in compiance with the doctors orders by 5/20/2022. Attachment # 7 |
05/20/2022
| Implemented |
| 6400.181(a) | Individual #1's assessment dated 2/12/21 and an updated assessment dated 10/24/21 included identical information in the following sections from the 3/6/20 assessment: progress over the past 365 calendar days in personal adjustment (section was left blank on all three assessments). The annual assessment should be updated each time it is due to accurately reflect the individual's current abilities, interests and functioning. | 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. | Individual #1 assessment was updated on 5/9/2022. Attachment #8 Program Specialists will be trained by 5/20/2022 on the completion of residential individual annual assessment. |
05/20/2022
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's annual assessment dated 2/12/21 and the updated assessment dated 10/25/21 did not assess progress over the last 365 calendar days in personal adjustment as this section was left blank on both assessments. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Individual #1 assessment was updated on 5/9/2022. Attachment #8 Program Specialists will be trained by 5/20/2022 on the completion of residential individual annual assessment. |
05/20/2022
| Implemented |
| 6400.34(a) | Individual #1 was informed of her rights on 12/23/2021. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include designated person, locking mechanism, access to bedroom, assistive technology, immediate access, direct service workers shall have the key or entry device to lock and unlock the door, and an individual's right may only be modified in accordance with § 6400.185 (relating to content of individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | 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 Rights Policy has been updated to reflect the current Chapter 6400 regulations of the 55 PA Code Chapter 6400.34 (a) Program Specialist will review most recent Indivdiual Rights Policy with indivduals by 5/20/2022. Attachment # 9 |
05/20/2022
| Implemented |