| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 was admitted into the program as an emergency placement on 7/14/2023. As of 2/1/2023, individual #1 had not participated in fire safety training to include: 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. [Repeat violation: 2/22/2023, et al.] | 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. | 07/14/2023 Individual #1 completed and documented Fire Safety training.
02/16/2024 Chief Program Officer created New Residential Placement Checklist which includes Fire Safety training to ensure completion of required documentation of Fire Safety. |
07/14/2023
| Implemented |
| 6400.141(a) | Individual #1 was admitted into the program as an emergency placement on 7/14/2023. As of 2/1/2023, individual #1 had not been seen by a primary care practitioner for a physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 02/16/2024 Chief Program Officer created New Residential Placement Checklist to include physical examination, vision, hearing, dates completed, etc. |
02/16/2024
| Implemented |
| 6400.181(a) | Individual #1 was admitted into the program as an emergency placement on 7/14/2023. As of 2/1/2023, an initial assessment had not been completed for individual #1. | 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. | 02/07/2024 Individual #1's initial assessment was signed and dated.
02/16/2024 Chief Program Officer created New Residential Placement Checklist which includes initial assessment to ensure completion of required documentation of initial assessment. |
02/07/2024
| Implemented |
| 6400.34(a) | Individual #1 was admitted into the program as an emergency placement on 7/14/2023. As of 2/1/2023, individual #1 had not been informed of their individual rights. [Repeat violation: 2/22/2023, et al.] | 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. | 02/06/2024 Individual #1 signed Individual Rights policy.
02/16/2024 Chief Program Officer created New Residential Placement Checklist which included Individual Rights to ensure completion of required documentation of Individual Rights Training. |
02/06/2024
| Implemented |
| 6400.182(b) | Individual #1 was admitted into the program as an emergency placement on 7/14/2023. As of 2/1/2023, an individualized support plan had not been developed for individual #1. | The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home. | 01/26/2024 Individual #1 was assigned to Allegheny County.
01/22/2024 Supports Coordinator was assigned to Individual #1.
02/07/2024 meeting for Individual #1's Individual Support Plan was held and draft ISP was completed.
02/16/2024 Chief Program Officer created New Residential Placement Checklist which includes Program Specialists developing ISP in absence of Supports Coordinator to ensure completion of required documentation of Individual Support Plan. " |
01/22/2024
| Implemented |