| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The carpet from the kitchen to the dining room had a large black stain with smaller black stains around the large spot. | Floors, walls, ceilings and other surfaces shall be in good repair. | Vinyl flooring has been laid in dining area. See Attachment #49. |
10/23/2017
| Implemented |
| 6400.71 | The telephone located in the staff room did not have the telephone number to the nearest hosptial on or near the phone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| New stickers, noting hospital number, were adhered to the staff room telephone. See Attachment #48. |
10/20/2017
| Implemented |
| 6400.80(a) | The exterior concrete area has numerous chunks of concrete missing and the concrete is splitting causing a tripping hazard. The individuals in the home use this area as an exit during fire drill evacuations. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | A contractor has been contacted to assess repair of concrete, but given the time of ear, it is likely repairs will not be completed until Spring of 2018. |
05/31/2018
| Implemented |
| 6400.80(b) | The exterior part of the staff room window has chipping paint. The gutter spout is missing the elbow juncture. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The windows have been scraped and painted. See Attachment #46
The gutter spout elbow juncture has been replaced. See Attachment #47a & 47b |
10/25/2017
| Implemented |
| 6400.141(c)(7) | Individual #1 had a pap test completed on 3/28/16 and not again until 4/19/17, after the annual time frame. | 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. | While Individual #1 was seen for pap test on 4/19/17, Conemaugh Physician Group printout from 3/28/16 pap test states, ¿Pap guidelines state paps no longer needed after age 65 if no abnormal paps in past 20 years. Every 2 years for visits if mandated by state regulations.¿ Staff instructed to schedule within one year if pap is required by physician, completed 10/27/17. See Attachments #44a & 44b. |
10/27/2017
| Implemented |
| 6400.141(c)(8) | Individual #1 had a mammogram completed on 4/1/16 and not again until 5/3/17, after the annual time frame established. | 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. | Staff instructed to schedule within one year. See Attachment #44a. |
10/27/2017
| Implemented |
| 6400.141(c)(11) | Individual #1's 10/12/16 physical exam form did not include an assessment of their health maintenance needs, medication regimen and the need for blood work at recommended intervals. The field 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. | Staff instructed to remind physician to complete Summary/Recommendations/Health Maintenance Needs/Follow-ups section for subsequent exams. See Attachment #44a |
10/27/2017
| Implemented |
| 6400.141(c)(15) | Individual #1's 10/12/16 physical exam form indicated "none" for dietary restrictions. However Individual #1's Individual Support Plan (ISP) indicated he/she followed an 1800 calorie, low sugar, low fat, low salt diet. His/Her 12/7/16 assessment indicated that since his/her admission (2009) he/she has been following his/her diet with staff assistance and has lost weight as a result. His/Her assessment also indicated that he/she can eat independently after his/her food is cut up. | The physical examination shall include:Special instructions for the individual's diet. | PCP was contacted confirmed he did not intend to discontinue diet, despite the reference to ¿none¿ for dietary restrictions on the annual physical. Staff were instructed to continue the 1800 calorie, low sugar, low fat, low salt diet, completed 10/20/17. Also, while Individual #1 may eat independently after her food is cut up, she does not shop for groceries nor prepare meals. Staff shops, prepares meals, and is responsible for Individual #1¿s diet. See Attachment #37. |
10/20/2017
| Implemented |
| 6400.144 | Individual #1 had a podiatrist appointment on 3/20/17 and not again until 8/2/17. He/She was to have a return podiatrist appointment on 5/22/17 however there is no documentation in his/her record that indicated he/she saw his/her podiatrist on 5/22/17. Individual #1's blood pressure reading was to be taken daily. Individual #1's blood pressure reading was not documented on 12/4/16. | 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.
| Seen by podiatrist on 05/22/17, as noted in medical narrative. See Attachment #45a. Also Podiatrist provided verification of appointments including 05/22/17. See Attachment #45b |
10/27/2017
| Implemented |
| 6400.167(b) | Individual #1 is prescribed Laxative 10mg insert 1 suppository rectally daily as needed if no bowel movement in 3 days for constipation. According to the bowel movement chart for July and June 2017, Individual #1 had a bowel movement on 7/5/17 and not again until 7/12/17, 7/23/17 and not again until 7/27/17, and on 6/22/17 and not again until 6/28/17. There was no documentation that that the Laxative was administered as prescribed for the dates listed above. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff instructed to administer as per procedure and to document administration. See Attachment #44 |
10/27/2017
| Implemented |
| 6400.181(e)(5) | Individual #1's 12/7/16 assessment did not include his/her ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Skill Assessment dated 12/7/16, states, ¿Individual #1 will take the Dixie cup of pills, pour them into her hand, place them in her mouth, and wash them down with a drink. She attained a goal previously of getting a cup of water to take her medication. Individual #1 has maintained her skills in area over the past year.¿ Her ISP states, ¿Individual #1 is not able to administer her own medication. With verbal prompts from staff she is able to get herself a glass of water, pick up the dixie cup ot pills, pour the pills into her hand, and swallow the pills with water ¿ all with verbal prompting and line-of-sight supervision. She cannot, however, name her medications, their dosages, or their functions.¿ This was included in addendum to Skill Assessment, 10/26/17. See Attachment #41 |
10/26/2017
| Implemented |
| 6400.181(e)(6) | Individual #1's 12/7/16 assessment did not include his/her ability to safety use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | In the Awareness of Danger/Safety Precautions section of her 12/7/16 skill assessment, the first sub section states, ¿Poisonous materials: Individual #1 is considered to be deficient in understanding poisonous items due to her lack of involvement and communication. She shows no interest in poisons and will not interfere with them so the poisons are not kept locked in the home.¿ See Attachments #42a & 42b. |
12/07/2016
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's 12/7/16 assessment did not include his/her progress and current level in health. His/Her assessment indicated that he/she made progress in health due to the implementation of a goal to brush his/her teeth. However the information that failted to make it to his/her assessment included regression due to a diagnosis of MRSA in 2016, recurrent skin picking, and recurring MRSA and abscesses on his/her body due to the skin picking. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Addendum to skill assessment was added on 10/26/17 as follows: Health (hygiene, diet, nutrition, exercise): Individual #1 was treated for a sore, an abscess, on her lower back on 5/28/16. Abscess was drained, antibiotics were prescribed . At follow-up on 6/1/16 MRSA was diagnosed. Additional follow-ups on 6/6/16, 6/14/16, 6/21/16, and on 7/7/16, when PCP discontinued treatment of antiseptic ointment and dressings. While Individual #1 continued to scratch herself often, no further incidents involving infections. See Attachment #41 |
10/26/2017
| Implemented |
| 6400.181(e)(13)(ii) | REPEAT from 12/14/16 renewal inspection: Individual #1's 12/7/16 assessment did not include his/her progress and current level in motor and communication skills. The section was verbatim to the 12/7/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Addendum to skill assessment on 10/26/17. No notable improvement in communication skills and Individual #1 continues to ambulate without a walker. See attachment #41 |
10/26/2017
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's 12/7/16 assessment did not include his/her progress and current level in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Addendum to skill assessment on 10/26/17: Individual #1 relies on staff for most food preparation. While she has used the microwave with staff assistance and might be able to prepare or help prepare simple uncooked items like sandwiches or cereal, she prefers staff prepare all food. Also, she brings her laundry basket from her room, but staff does her laundry for her. Skills were maintained. See Attachment #41 |
10/26/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's 12/7/16 assessment did not include his/her progress and current level in recreation. This section was verbatim to the 12/7/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Addendum to skill assessment on 10/26/17: Individual #1's interests and activities, including puzzles, games, beads, music, eating, movies, and television, have not changed. She maintained skills. See Attachment #41 |
10/26/2017
| Implemented |
| 6400.181(e)(13)(vii) | REPEAT from 12/14/16 renewal inspection: Individual #1's 12/7/16 assessment did not include his/her progress and current level in financial independence. This section was verbatim to the 12/7/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Addendum to skill assessment on 10/26/17: Individual #1's skills in this area continue to be limited. She demonstrates no concept of numbers or money. Her brother remains payee for her benefits. Her skills were unchanged, or maintained. See Attachment #41 |
10/26/2017
| Implemented |
| 6400.181(e)(13)(viii) | REPEAT from 12/14/16 renewal inspection: Individual #1's 12/7/16 assessment did not include his/her progress and current level in managing personal property. This section was verbatim to the 12/7/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Addendum to skill assessment on 10/26/17: Individual #1 continues to seem to be aware of her belongings in her bedroom and to usually sit in a specific chair in the living room. She continues to leave alone items which do not belong to her. She continues to require nearly total assistance to purchase items. Her skills were maintained. See Attachment #41 |
10/26/2017
| Implemented |
| 6400.181(f) | Individual #1's 12/7/16 assessment was not sent to team members 30 days prior to her annual Individual Support Plan (ISP) meeting. The assessment was sent on 12/7/16 and his/her ISP meeting was held 1/3/17. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Executive Director trained the Program Specialist that they shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP in accordance with ODP regulations. See Attachment #43 |
10/30/2017
| Implemented |
| 6400.183(5) | Individual #1's Individual Support Plan (ISP) did not include a protocol to address the social, emotional and environmental needs of the individual. He/She was prescribed medication to treat Depression and Anxiety. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Supports Coordinator was requested to include the CRS plan of support for Individual #1 in their ISP. Requested from SC and copy sent to SC. See Attachments #39a & 39b |
10/26/2017
| Implemented |
| 6400.183(7)(iii) | Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | ISP, dated 02/01/17, states in Employment/Volunteer Information section, "Individual #1 is not a candidate for employment due to her age, and medical and cognitive limitations. Individual #1 enjoys going to day program. The team discussed employment at her ISP annual review and all are in agreement that Individual #1 would not benefit from any employment services. See Attachments #40a & 40b. |
02/01/2017
| Implemented |
| 6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| ISP, dated 02/01/17, states in Employment/Volunteer Information section, "Individual #1 is not a candidate for employment due to her age, and medical and cognitive limitations. Individual #1 enjoys going to day program. The team discussed employment at her ISP annual review and all are in agreement that Individual #1 would not benefit from any employment services. See Attachments #40a & 40b. |
02/01/2017
| Implemented |
| 6400.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews dated 6/15/17, 3/14/17, 12/14/16, 9/12/16, and 6/12/16 did not review his/her social, emotional, environmental plan of support. His/Her 6/15/17 ISP review did not review his/her dental hygiene plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Subsequent ISP reviews (quarterly reviews) will include review of plan of support and dental plan. This was reviewed by supervisors responsible for reviews and documented on 10/26/17. See Attachment #38 |
10/26/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks. This section was left blank on the facesheet and was not indicated anywhere else in his/her record. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual #1's face sheet was updated including identifying marks. See Attachment #36. |
10/11/2017
| Implemented |
| 6400.213(11) | Individual #1's 10/12/16 physical exam form indicated "none" for dietary restrictions. However Individual #1's Individual Support Plan (ISP) indicated he/she followed an ADA 1800 calorie, low sugar, low fat, low salt diet. His/Her 12/7/16 assessment indicated that since his/her admission (2009) he/she has been following his/her diet with staff assistance and has lost weight as a result. His/Her assessment also indicated that he/she can eat independently after his/her food is cut up. Individual #1's 12/7/196 assessment indicated that he/she required 24 hours supervision in the home and community. His/Her ISP updated 2/1/17 indicated that he/she is monitored in the group home and can be left alone in the room for short periods of time with periodic line-of-sight supervision. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | PCP was contacted and confirmed he did not intend to discontinue diet, despite reference to "none" for dietary restrictions on annual physical. Staff were instructed to continue the 1800 calorie, low sugar, low fat, low salt diet. See Attachment #37
Also, while individual #1 may eat independently after her food is cut up, she does not shop for groceries nor prepare meals. Staff shops, prepares meals and is responsible for Individual #1's diet. As to the reference to supervision, while 24 hour supervision is provided in the home, Individual #1 may be left alone in a room for short periods of time with periodic line-of-sight supervision. This distinction is to clarify that she does not require 24 hour line-of-sight or within arms-length supervision. |
10/20/2017
| Implemented |
| 6400.216(a) | Individual's previous years medical records were left unlocked and accessible in the staff area. | An individual's records shall be kept locked when unattended. | A training memo was created and sent to direct support professionals indicating the regulation of all individuals records need to be locked when not attended. An individual record shall be kept locked when unattended. The individual and the individual's parent, guardian or advocate shall have access to the records and to information in the records. If the interdisciplinary team documents that disclosure of specific information constitutes a substantial detriment to the individual or that disclosure of specific information will reveal the identity of another individual or breach the confidentiality of persons who have provided information upon an agreement to maintain their confidentiality, that specific information identified may be withheld. See Attachment #22 |
10/20/2017
| Implemented |