| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The entire home needs attention and cleaned properly. Home is dusty; floors need cleaned and mopped; the upstairs bathroom window was full of dirt and debris; kitchen counters were sticky; toaster oven in kitchen was rusted and sticky from food. Clothes and other items strewn in rooms. | Clean and sanitary conditions shall be maintained in the home. | Attachments 14a-c are photos of impacted areas since staff were assigned updated cleaning tasks. The toaster oven has been discarded. Attachment 14d is an example of staff chore chart. Staff with better history of home maintenance and oversight have been rotated into the home¿s staffing pattern to better maintain future compliance and model for other staff. We are utilizing a physical site checklist that corresponds to pertinent licensing regulations. Attachment 13f is an example of the checklist utilized within this home. The checklist will be utilized by an assigned Program Manager as part of our LII and by Site Supervisors periodically in their home to better maintain compliance moving forward. |
10/01/2015
| Implemented |
| 6400.67(a) | The radiator in the bathroom is covered in rust; repaint outside around the front door; Indiv #3 window blind is torn; replace the rubber surface on the bottom step of the main stairway. | Floors, walls, ceilings and other surfaces shall be in good repair. | Attachments 13a-e are pictures of the corrected items noted above. We are utilizing a physical site checklist that corresponds to pertinent licensing regulations. Attachment 13f is an example of the checklist utilized within this home. The checklist will be utilized by an assigned Program Manager as part of our LII and by Site Supervisors periodically in their home to better maintain compliance moving forward. |
10/01/2015
| Implemented |
| 6400.110(g) | Indiv #1 bed shaker did not operate when fire alarm located in his bedroom was sounded. | If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. | The bed shaker in individual #1¿s room was not interconnected to the house alarm system. It had an independent smoke detector in his room which operated it. As a result of the inspection, we purchased new alarms/detectors for all floors of the home that are interconnected and also capable of transmitting a signal to Individual¿s #1¿s bed shaker. Whenever the interconnected alarm now sounds, the bed shaker will operate. The independent smoke detector is still located in his room and is operable. Attachment 12a-b are copies of receipts for this additional equipment. This was installed by our maintenance staff. |
09/01/2015
| Implemented |
| 6400.181(a) | Indiv #2 annual assessment was late. Completed 1/11/2013 and not again until 10/10/2014. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Attachment 9c is an assessment completed since licensing for Individual #2. Attachment 11a is the prior assessment for the same individual showing compliance. This regulation was included in training for our 6400 Program Specialists in order to maintain future compliance. Confusion existed regarding annual completion of assessment and the expectation to provide to SC 30 days in advance of meeting. It was clarified that the expectation is at least 30 days prior to annual review, therefore both standards can be met while maintaining compliance. Attachment 17 is signature sheet from staff training and summary of topics covered. Attachments 11b-c represent a current assessment completed since licensing and the individual¿s previous assessment completed in compliance. |
09/28/2015
| Implemented |
| 6400.186(b) | Indiv #2 did not sign and date ISP reviews. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | We have used the Licensing Inspection Instrument provided by the Department to guide our forms and expectations with this regulation. The LII does not indicate that a consumer must also date the review. However, this language is contained within the PA Code. This clarification was included in training for our 6400 Program Specialists in order to maintain future compliance. Attachment 10a is Individual 2¿s most recent review and attachment 10b is another consumer review done since our inspection in compliance. Attachment 17 is signature sheet from staff training and summary of topics covered. |
08/01/2015
| Implemented |
| 6400.186(c)(2) | In indiv #2 ISP reviews the Behavior Support Plan and supervision needs are not being reviewed. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The ISP, BSP, and assessment for Individual 2 has had pertinent sections reviewed and updated with the SC. Attachment 9a-c represent the review and changes to the supervision section of the ISP, BSP, and assessment respectively. Attachment 9d represents the communication of these changes to the SC. All plans, based on consumer participation in 2380 or 6400 programming, will be reviewed internally by a PS Supervisor prior to submission to SC in order to maintain future compliance. These reviews are done electronically using the `track changes¿ function and stored within each consumer¿s electronic record. Additionally, we will no longer copy the supervision in total from the ISP into the BSP, but rather note that the supervision is considered restrictive or not. As it not necessary to have these additional details, it will remove the potential for discrepancy. Attachment 9e represents a BSP since licensing that illustrates the updated language. Attachment 17 is signature sheet from staff training and summary of topics covered. |
08/05/2015
| Implemented |
| 6400.195(f) | Indiv #2 restrictive procedure plan states supervision at the home is 2:1; however sometimes the staff to indiv ratio is only 1:1. | The restrictive procedure plan shall be implemented as written.
| The BSP for Individual #2 did not contain current revision to supervision needs. The ISP, BSP, and assessment for Individual 2 has had pertinent sections reviewed and updated with the SC. Attachment 9a, b, and c represent the review and changes to the supervision section of the ISP, BSP, and assessment respectively. Attachment 9d represents the communication of these changes to the SC. All plans, based on consumer participation in 2380 or 6400 programming, will be reviewed internally by a PS Supervisor prior to submission to SC in order to maintain future compliance. These reviews are done electronically using the `track changes¿ function and stored within each consumer¿s electronic record. Additionally, we will no longer copy the supervision in total from the ISP into the BSP, but rather note that the supervision is considered restrictive or not. As it not necessary to have these additional details, it will remove the potential for discrepancy. Attachment 9e represents a BSP since licensing that illustrates the updated language. Attachment 17 is signature sheet from staff training and summary of topics covered. |
08/05/2015
| Implemented |
| 6400.213(11) | Indiv #2 ISP, BSP, and Assessment are not consistent regarding staff ratio and supervision needs. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The ISP, BSP, and assessment for Individual 2 has had pertinent sections reviewed and updated with the SC. Attachment 9a, b, and c represent the review and changes to the supervision section of the ISP, BSP, and assessment respectively. Attachment 9d represents the communication of these changes to the SC. All plans, based on consumer participation in 2380 or 6400 programming, will be reviewed internally by a PS Supervisor prior to submission to SC in order to maintain future compliance. These reviews are done electronically using the `track changes¿ function and stored within each consumer¿s electronic record. Attachment 17 is signature sheet from staff training and summary of topics covered. |
08/05/2015
| Implemented |