| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | On 2/9/2023, individual #2's bedroom did not contain a mirror. | In bedrooms, each individual shall have the following: A mirror. | on 2/9/23, the program specialist purchased a mirror and the maintenance department installed it the same day. Photographic proof was emailed to the licensing representative lead; that email will be forwarded to the licensing supervisor. |
02/09/2023
| Implemented |
| 6400.141(c)(7) | Individual #1's had a gynecological examination completed on 12/2/2021, and then again on 1/23/2023. This exceeds the annual requirement. | 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. | Individual #1 moved into the Arc's residential program on 11/9/2022 from a provider in Allegheny county and had to have all medical providers transferred to the local area at the guardian's request. The first available appointment was when the appointment was conducted on 1/23/2023. An attempt was made to acquire medical documentation stating this, but the medical provider said such documentation must be requested when the appointment is scheduled and not after the fact. The next annual appointment is scheduled to avoid further issue and is slated to occur on 1/25/2024. |
01/23/2023
| Implemented |
| 6400.181(d) | Individual #1's assessment was signed and dated by the program specialist on 1/10/2023; however, the assessment was sent to the plan team members on 1/7/2023, prior to the completion of the assessment. | The program specialist shall sign and date the assessment. | The Program Specialist was retrained on this regulation in it's entirety - proof of the training will be emailed to the licensing supervisor upon submission of this plan of correction. |
02/10/2023
| Implemented |