| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | (Repeat from 8/26/24, 4/17/25) Individual #1 is 69 years old and receives residential services. They require verbal prompts to initiate their Activities of Daily Living (ADLs) but they are independent in toileting, hygiene, and grooming tasks and will ask for help when needed. The individual requires line-of-sight supervision during mealtimes.
According to Individual #1's Lifetime Medical History, the individual was diagnosed with dysphagia on 1/29/19. On 8/15/25, the individual choked during dinner, and the Heimlich Maneuver had to be performed. On 9/10/25, the individual's diet had changed to a Level 7 easy chew diet after the choking incident. A Level 7 chew diet consists of regular easy to chew foods that can be cut or broken apart with the side of a fork or spoon.
From the time that the physician had ordered a Level 7 diet on 9/10/25, the individual has been given two sugar free hard candies as a snack every day since 9/11/25 to the current date of 10/3/25. Failure to follow the physician's instructions could pose a choking hazard conducive to serious injury or death due to the individual's dysphagia diagnosis. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Program Supervisor contacted Geisinger Danville on 10/6/25 and individual #1 is now scheduled for a swallow study on 10/20/25. The Program Supervisor retrained all staff on 10/10/25 in CSG's policies on Abuse and Neglect, Incident Management, Health Services for Individuals in IDD Services, and the requirements of this regulation to ensure understanding in their responsibility to follow prescribed protocols, and reporting incidents according to the IM Bulletin. At this time, staff also received specific retraining in individual #1's diet protocol, including providing education when individual #1 chooses foods that do not align with their diet and could pose a choking hazard. It was reviewed with staff that failure to follow individual #1's diet could lead to another choking incident, which could cause serious injury or death due to individual #1's dysphagia diagnosis. An incident report for neglect was filed in EIM on 10/10/25 for not following individual #1's diet prescribed by their physician. Please see supporting documentation. |
11/28/2025
| Implemented |
| 6400.141(c)(8) | Individual #1 was seen on 6/12/24 and has not had a mammogram since this date, which is outside of the annual time frame. | 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. | Program Manager contacted the Breast Center on 10/6/25 and scheduled a mammogram for individual #1 on 10/28/25. Program Supervisor retrained staff on the requirements of this regulation on 10/10/25. Please see supporting documentation. |
11/28/2025
| Implemented |
| 6400.32(c) | (Repeat from 8/26/24 and 4/17/25) At Individual #1's cardiology appointment on 7/9/25, the physician had documented that the individual is to "keep their blood pressure systolic less than 150 with Metoprolol and to notify the physician if their systolic blood pressure is greater than 150. There is not a blood pressure protocol in place and there are no records being maintained verifying that the individual's blood pressure is being monitored.
-Individual #1 has a diabetes protocol that their blood sugar levels are tested 2 times daily before meals at breakfast and dinner. The individual's blood sugar level should fall between 80-120 before meals and around 150 2 hours after snacks/meals. If blood sugar level exceeds 150 for at least one week, Teresa Hershberger's office needs to be contacted. If blood sugar level drops under 70 she will receive 4oz fruit juice and recheck level after 15-20 minutes, then offer a light snack.
The individual's blood sugar levels are not documented at every testing, which makes tracking the individual's blood sugar level difficult to monitor if the individual's blood sugar level would exceed 150 for at least one week. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Program Supervisor contacted individual #1's cardiologist on 10/9/25 for clarification on blood pressure monitoring. A fax was received from the cardiologist on 10/10/25 stating individual #1's blood pressure does not need to be monitored at home. The Program Supervisor retrained all staff on 10/10/25 in CSG's policies on Abuse and Neglect, Incident Management, Health Services for Individuals in IDD Services, and the requirements of this regulation to ensure understanding in their responsibility to follow prescribed protocols, and reporting incidents according to the IM Bulletin. At this time, staff also received specific retraining in individual #1's updated order regarding blood pressure monitoring and individual #1's diabetes protocol. An incident was filed in EIM for neglect on 10/10/25 regarding not following protocols for blood pressure monitoring and diabetes. Please see supporting documentation. |
11/28/2025
| Not Implemented |
| 6400.213(1)(i) | Individual #1's photograph is not current as it was last updated on 9/27/24, which was not updated within the annual time frame to be considered as current. | Each individual's record must include the following information: Current Photo | Program Supervisor updated the photograph of individual #1 in the record on 10/10/25. Staff were trained by the Program Supervisor in the requirements of this regulation that photographs must be updated annually on 10/10/25. Please see supporting documentation. |
11/28/2025
| Implemented |