Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.68(c) | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. The agency provided water testing documents dated 11/17/22, 2/16/23 and 6/6/23. This exceeds the time requirement. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Provider's water testing laboratory went out of business with little notice. The provider established accounts with a new water testing laboratory and testing was done as quickly as possible but exceeded the quarterly requirement, resulting in a late water test. |
08/23/2023
| Implemented |
6400.141(a) | The individuals should have a physical exam prior to moving in and then annually thereafter. Individual #1 had his physical exam prior to his admission on 12/3/21. The next physical exam was not completed until 1/5/23. This exceeds the time frame. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Provider added a note to individual #1's file to explain why the physical exam was late. Provider reviewed upcoming annual physical due dates to ensure that appointments were scheduled within annual time frame. |
08/25/2023
| Implemented |
6400.142(a) | Individual #1 has not had a dental exam since living at the program. Individual #1 had an appointment on 10/25/22 at Tobyhanna Dental which the Dentist did not complete an exam and was referring Individual #1 to see a Dentist who specialized with special needs. The agency contacted several dental offices on 10/31/22 all of which were not taking new patients, or they were not accepting Individual #1's insurance. The next attempt at calling for a dental was on 1/16/23 which was unsuccessful. The next attempt to schedule Individual #1 was on 8/3/23 which reflects he has an appointment on 8/28/23 at 12:30pm at Tobyhanna Dental. This was the dental provider who referred Individual #1 out last October. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1 has a dental appointment scheduled on 8/28/23 and 9/26/23. These appointments were made with 2 different dental providers in case the first appointment was unsuccessful. Program supervisors were retrained on what resources to use to find providers covered by the individual's insurance. |
08/25/2023
| Implemented |