| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The self-assessment was completed 2/4/14 and the expiration date is 3/1/14. | (a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.
| Program Manager was retrained on the regulation by the Assistant Director of Adult Services on 03/04/2014(Attachment #1) |
03/04/2014
| Implemented |
| 6400.31(b) | Individual #1's Individual Rights sign off was not completed annually. They were signed on 11/19/12 then not again until 12/5/13. | (b) Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #2). In the future, all annual documentation will be reviewed with the residents on the first business day in January and annually thereafter. Individual Rights that are in compliance are attached (Attachment #3). |
03/04/2014
| Implemented |
| 6400.67(a) | Living room area needs painted, chipping paint at floor under bay window, large black marks on wall behind the kitchen chairs. | (a) Floors, walls, ceilings and other surfaces shall be in good repair.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #4). The repairs and painting are scheduled to be completed by 6/30/2014, appropriate documentation will be forwarded at that time. |
06/30/2014
| Implemented |
| 6400.141(a) | Individual #1's annual physical was not completed annually. It was completed on 4/27/12 and then not again until 5/20/13. | (a) An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #5). Individual #1 was scheduled for oral surgery on 6/6/2013 and it was requested that her physical exam not be more than 30 days old at the time of surgery, so the physical was pushed back until 5/20/2013. Documentation was in the individual file at the time of inspection (Attachment #6). |
03/04/2014
| Implemented |
| 6400.151(a) | Staff person #1's phyiscal exam was late. Completed 1/29/10 then not again until 2/21/12. | (a) A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #7). Staff person #1 had a physical exam completed on 2/12/2014 (Attachment #8). |
03/04/2014
| Implemented |
| 6400.151(c)(2) | Staff person #1's Mantoux was late. Was completed 5/11/09 and then not again until 2/23/12 | (2) Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #9). Staff person #1 had a tuberculin skin test completed at the time of her physical on 2/12/2014 (Attachment #8). |
03/04/2014
| Implemented |
| 6400.181(f) | The annual assessment for Individual #1 was not provided to the Supports Coordinator. | (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).
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #10). House Managers will ensure that documentation reflects that the assessment is mailed to the Supports Coordinator and team member 30 calendar days prior to the ISP(Attachment #11 is s sample memo that will be used at all houses when mailing out the assessment. |
03/04/2014
| Implemented |
| 6400.183(7)(i) | The annual assessment for Individual #1 did not review the potential to advance in Residential Independence. | (7) Assessment of the individual's potential to advance in the following:
(i) Residential independence.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #12). Email sent to the SC for individual#1 requesting that they add a statement in regards to advancement in regards to residential independence (Attachment #13). |
05/30/2014
| Implemented |
| 6400.184(a) | The Program Specialist or Program Specialist designee did not attend Individual #1's ISP meeting. | (a) The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 6400.186 (relating to ISP review and revision).
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #14). House Manager Trisha McKeehan attended Individual #1's ISP meeting in lieu of the Program Manager. The diploma from Bloomsburg University shows she meets the requirements of a Program Specialist (Attachment #15). |
03/04/2014
| Implemented |
| 6400.186(c)(2) | The ISP reviews for Individual #1 did not review the dental plan that is in place. | (2) A review of each section of the ISP specific to the residential home licensed under this chapter.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #16). A ISP review for Individual #1 is attached showing the review of her dental plan (Attachment #17) |
02/28/2014
| Implemented |
| 6400.213(11) | Individual #1's ISP and Physical contain content discrepancy in the diet section. ISP states low fiber diet, low residue diet and to puree food. The physical states no diet restrictions. | (11) Content discrepancy in the ISP, The annual update or revision under § 6400.186.
| Program Manager and House Managers were retrained on the regulation by the Assistant Director of Adult Services on 3/4/2014 (Attachment #18). The 2013 physical was updated by the House Manager to reflect the correct dietary restrictions (Attachment #19) also 2014 physical shows the correct dietary restrictions for individual #1 (Attachment #20) |
05/22/2014
| Implemented |