| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Written fire drill records were not available for fire drills held from 1/1/19 to 9/24/19. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | UCIP's office at 17999 Cussewago Road, Meadville PA 16335 experienced a fire on 9/18/19. Records of completed monthly fire drills for the South Morgan location were kept in this office and were destroyed. Program Specialist Matt Morian does have record of fire drills done on 9/24/19, 10/9/19, 11/14/19 and 12/13/19. Program Specialist Matt Morian will continue to complete and document fire drills monthly according to what is outined in the regualations set by ODP.[Immediately and upon hire, the CEO or designee shall educate all staff persons responsible for conducting, documenting and maintaining records on the procedures of maintaining written fire drill records to include all required information. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
| 6400.113(a) | Individual #1, date of admission 9/29/19 was instructed in fire safety on 10/02/19. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Original Fire Safety for [Individual #1] was completed prior to the fire at UCIP on 9/18/19. Program Specialist Matt Morian completed a second Fire Safety on 10/2/19. [Immediately, upon admission and at least annually, the CEO or designee shall audit all individual's records to ensure all individuals have a current fire safety instruction. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |
| 6400.34(a) | Individual #1, date of admission 9/26/19 was informed of individual rights and the process to report a rights violation on 11/26/19. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | UCIP has developed an admission checklist of items needed to meet licensing regulations for new individuals. This checklist will be completed prior to or on the day of admission to prevent this from reoccurring. Program Specialist Matt Morian will continue to review rights with individuals annually.[Immediately, upon hire and at least annually, the CEO or designee shall educate the program specialists of their responsibilities to ensure all individuals are inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. Upon admission and at least annually, the CEO or designee shall audit the aforementioned checklist to ensure completion and that all individual are informed and explained individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 1/23/20)] |
01/22/2020
| Implemented |
| 6400.165(g) | The review of medications, Topamax and Zoloft prescribed to treat symptoms of a psychiatric illness completed on 12/2/19 for Individual #1 did not include the reason or prescribing the medications. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | [Individual #1's] Primary Care Physician was contacted by Program Specialist Matt Morian regarding 9/18/19 visit. Office documentation of the visit was collected. Documentation did indicate diagnosis and reason for medication. Program Specialist Matt Morian made changes to UCIP's appointment form on 12/20/19 to reflect this information. [Upon completion, the CEO or designee shall audit all individual's medication reviews to ensure all individuals required information is included and individuals are administered the medications as prescribed. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] |
01/22/2020
| Implemented |