| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.61(b) | Beginning in August 2021, Individual #2 was not being bathed in the bathtub in the bathroom in the home. The direct service workers are unable to maneuver Individual #2's legs over the side of the bathtub without Individual #2 becoming upset. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home. | Since individual #2 has lived in her home for approximately 30 years and does not want to move we have secured a contractors and are making the installation of a roll in shower instead of a bath tub a priority in her home. We are anticipating this being done by June 11, 2022 if all goes accordingly. A physical therapist came to the home on Friday April 22nd and assessed individual #2. This assessment included range of motion, ability to stand and transfer, ability to transfer from wheelchair to multiple chairs and evaluation of existing adaptive equipment. During the course of the evaluation the Physical Therapist also instructed staff on safe ways to transfer individual number #2. Present for this assessment was Program Specialist, Daylight DSP, Afternoon DSP and Nurse Consultant. Physical Therapist also evaluated existing adaptive equipment and said that the sliding shower bench may be the best option. Physical Therapist said that she would recommend some strengthening therapy as well as practice using the sliding shower bench with staff and the individual in an attempt to help the individual become more comfortable with showering. Occupational Therapist did an initial evaluation in the home on 4/25. Occupational therapy will continue.
Due to continued refusal by individual #2 to use the shower bench in the bath tub staff will continue to sponge bath individual #2 until a roll in shower is available. Staff will be instructed to document these refusals correctly and offer counseling about the importance of personal hygiene.
All staff working with individual #2 will receive training on how to properly use any and all equipment recommended by physical therapy and occupational therapy. |
06/11/2022
| Implemented |
| 6400.67(a) | On 4/13/2022, there were three panels missing from basement ceiling and one panel that was sagging from what appeared to be water damage. | Floors, walls, ceilings and other surfaces shall be in good repair. | The panels have been replaced. Moving forward staff will immediately put an online request in for maintenance. |
05/04/2022
| Implemented |
| 6400.112(f) | The monthly fire drills completed from April 2021 through March 2022 used the front door of the home as the exit route. There is more than one exit from the home. | Alternate exit routes shall be used during fire drills. | The Fire drill policy was updated on 4/27/2022 to reflect that Alternate exit routes will be used two (2) times a year during fire drills except in facilities where there is only one exit or if only one exit is accessible to the individuals. If an individual is physically unable to use alternate exits then they can use the same accessible exit for all drills. Those individuals that can exit the alternative routes should use them, two (2) times a year. All staff will be trained on new policy by 5/15/22 |
05/15/2022
| Implemented |
| 6400.141(c)(7) | Individual #1 had a gynecological examination completed 12/15/2020 and then again 2/3/2022. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The program specialist will make a spreadsheet to address the citations in regards to the late annual required medical appointments. Prior to leaving medical appoints staff will schedule follow up appoints as well as yearly appointments needed for the following year. The spreadsheet will posted at the site. |
05/17/2022
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 4/8/2021 did not include blood work at recommended intervals. This section was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The current annual physical completed for Individual #1 on 4/21/22 includes that blood work is recommended annually. |
05/17/2022
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 4/8/2021 did not include medical information pertinent to diagnosis in the case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The current annual physical completed for Individual #1 on 4/21/22 indicates there is no (Doctor indicated this using a zero with a slash through it) medical information pertinent to diagnosis and treatment in case of an emergency. |
05/15/2022
| Implemented |
| 6400.32(d) | Beginning in August 2021, Individual #2 was not being bathed in the bathtub in the bathroom in the home. The direct service workers have been utilizing a portable water storage/showering device and mobile shower chair to perform Individual #2's personal hygiene. The device was being used in various rooms of the home including the dining room and living room. When inquired by the Department as to why this was occurring, Program Specialist #1 and Direct Service Worker #2 reported they are unable to bathe Individual #2 in the bathtub that is in the home due to Individual #2's mobility. Individual #2 is diagnosed with Cerebral Palsy. Individual #2 will exhibit refusal behaviors around bathing in the bathtub in the home. The direct service workers are unable to maneuver Individual #2's legs over the side of the bathtub without Individual #2 becoming upset. | An individual shall be treated with dignity and respect. | Since individual #2 has lived in her home for approximately 30 years and does not want to move we have met with multiple contractors and are making the installation of a roll in shower instead of a bath tub a priority in her home. Our goal is to have this completed by June 11, 2022.
We are unclear of why it states that individual #2 was being bathed throughout the house. We were told by staff only in the bedroom and bathroom in private.
A physical therapist from Allegheny Health Network did come to the home on Friday April 22nd and assessed individual #2. This assessment included range of motion, ability to stand and transfer, ability to transfer from wheelchair to multiple chairs and evaluation of existing adaptive equipment. During the course of the evaluation the Physical Therapist did also instruct staff on safe ways to transfer individual number #2. Present for this assessment was Program Specialist, Daylight DSP, Afternoon DSP and Nurse Consultant. Physical. Physical Therapist also evaluated existing adaptive equipment and said that the sliding shower bench may be the best option. Physical Therapist said that she would recommend some strengthening therapy as well as practice using the sliding shower bench with staff and the individual in an attempt to help the individual become more comfortable with showering.
Occupational Therapist is scheduled to do an evaluation in the home on either 4/25 or 4/26 with OT therapy to follow.
All staff working with individual #2 will receive training on how to properly use any and all equipment recommended by physical therapy and occupational therapy.
Individual #2 will continue to be supported in her right to refuse a shower. Staff will be instructed to document these refusals correctly and offer counseling about the importance of personal hygiene. |
06/11/2022
| Implemented |
| 6400.32(h) | Beginning in August 2021, Individual #2 was not being bathed in the bathtub in the bathroom in the home. The direct service workers have been utilizing a portable water storage/showering device and mobile shower chair to perform Individual #2's personal hygiene. The device was being used in various rooms of the home including the dining room and living room. | An individual has the right to privacy of person and possessions. | A certified investigation was conducted and no evidence was found indicating that individual #2 was being showered using the portable showering/camp shower device in any area of the home other than the bedroom and this was done in privacy. |
06/01/2022
| Implemented |
| 6400.46(d) | Direct Service Worker #3 completed first aid, Heimlich techniques and cardio-pulmonary resuscitation training on 7/25/2019 and then again 2/2/2022. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | DSW #3 will schedule all mandatory trainings in advance of the due date and will put in on their Outlook calendar and will use the reminder function. |
06/01/2022
| Implemented |
| 6400.165(g) | Individual #1 had psychiatric medication reviews completed 9/28/2021 and then 2/3/2022. | 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. | The program specialist will make a spreadsheet to address the citations in regards to the late annual physical, assessments, required medical appointments, current ISP date. Prior to leaving medical appoints staff will schedule follow up appoints as well as yearly appointments needed for the following year. The spreadsheet will posted at the site. |
05/17/2022
| Implemented |
| 6400.181(f) | The program specialist provided Individual #1's assessment, completed 9/4/2021 to the plan team members on 9/3/2021 for the individual plan meeting on 10/1/2021. | 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 specialist will make a spreadsheet to address the citations in regards to the annual assessment being sent to plan team members less than 30 days prior to the meeting. The spreadsheet will posted at the site. |
06/01/2022
| Implemented |