| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The annual furnace inspection, completed on 11/21/2022, does not indicate if the furnace was cleaned. | 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.
| By 03/31/2023, Vice President of Special Projects and Facilities will update documentation to reflect cleaning occurs concurrently with the documented inspection. |
03/31/2023
| Implemented |
| 6400.142(e) | Individual #1's dental examination, completed 4/19/2022, indicated a need for a 6-month follow-up appointment. The follow-up appointment has not occurred. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | "Lifesteps Medical Examination forms from 2021 and 2022 provided at time of licensing shows that Primary Care Physician (PCP) stated ""Missing teeth, yearly dental exam no longer required."" Additional letter from PCP clarifying the medical reason for the deferment dated 02/23/2023 provided at the time of licensing.
Community Homes Director notified Guardian of licensing requirements. Guardian will consult with Licensed Dentist for recommendation of annual dental exam. If Licensed Dentist does not recommend an annual exam, the Guardian, as surrogate healthcare decisionmaker, will provide documentation requesting that Lifesteps seek a waiver to 142a if medically recommended." |
02/23/2023
| Implemented |
| 6400.165(g) | Individual #1's psychiatric medication reviews were completed on 6/3/2022 and then again 11/1/2022. [Repeat violation, 3/4/2022] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Community Homes Director marked Lifesteps out on 165g for Individual #1's psychiatric medication review during self-assessment conducted 01/27/2023 in accordance with 55 Pa. Code § 6400.15. |
04/27/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include color of eyes. | Each individual's record must include the following information: Personal information, including: The race, height, weight, color of hair, color of eyes and identifying marks. | 02/22/2023, Program Specialist updated Individual #1 Emergency Medical Information template to include eye color and hair color. |
02/22/2023
| Implemented |