| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 1/3/23, the agency certificate of compliance expires 8/27/2023. | 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.
| LIIs are scheduled to be completed beginning on the week of 3/20/23. Once completed, the LIIs will be turned into the Director of Compliance for review and to maintain. |
05/27/2023
| Implemented |
| 6400.21(a) | Temporary Direct Service Worker #3 was hired on 9/10/21 and had a criminal history record check conducted on 10/24/19. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Human Resources contacted the Staffing Agency and requested a new PA criminal history record check for Temporary Direct Service Worker #3. Record check is currently under review. |
03/16/2023
| Implemented |
| 6400.66 | On 3/1/23, there was no nearby lighting source observed outside of the garage's only man door. [Repeated Violation---3/29/22.] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The light was installed on 3/15/23. The outside lighting in addition to the outside conditions of the home will be reviewed upon the completion of the 2023 LII, which is scheduled to be completed the week of 3/20/23. |
03/15/2023
| Implemented |
| 6400.81(h) | On 3/1/23, Individual #1's and Individual #2's shared bedroom in the basement was observed with having only one glass-block window, thus preventing a view to the outside. | Each bedroom shall have at least one exterior window that permits a view of the outside. | The individuals bedrooms were moved to the above grade first floor on 3/15/23. |
03/15/2023
| Implemented |
| 6400.104 | The home's Local Fire Department Notification Letter did not include the exact location of the individuals' bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Letters to the local Fire Department were updated to include bedroom locations and mailed on 3/20/23. All supervisors were instructed to review their letters and confirm that they include the location of bedrooms and are accurate with the needs of the individuals no later than 3/17/23. |
03/20/2023
| Implemented |
| 6400.142(f) | Individual #1's record did not include any dental hygiene plans. Individual #1's 11/22/22 assessment indicates that they are not dental-hygiene independent. [Repeated Violation---3/29/22.] | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The individual is assessed as independent with dental hygiene in both their functional assessment and ISP. Per regulations, they do not need a dental hygiene plan. |
04/15/2023
| Implemented |
| 6400.46(a) | The general fire safety training for Temporary Direct Service Worker #4 completed on 3/9/22 was not specific to the home(s) in which they worked. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The Temp DSP has been contacted and will complete required site specific trainings no later than 3/31/23. |
03/31/2023
| Implemented |
| 6400.46(b) | The general fire safety training for Temporary Direct Service Worker #3 completed on 10/29/22 was not specific to the home(s) in which they worked. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The Temp DSP has been contacted and will complete required site specific trainings no later than 3/31/23. |
03/31/2023
| Implemented |
| 6400.51(b)(1) | Temporary Staff Direct Service Worker #4's date-of-hire is 3/16/22. Their orientation completed on 3/9/22 did not include completion documentation of the following required training topics: the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Human Resources contacted the Staffing Agency and requested training documentation for the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships for Temporary Direct Service Worker #4. It was communicated these trainings must be completed for Temporary Direct Service Worker #4 to continue to be assigned to work at Milestone Centers. Human Resources will be responsible for ensuring the training materials meet regulatory compliance. |
04/28/2023
| Implemented |
| 6400.51(b)(2) | Temporary Direct Service Worker #4's date-of-hire is 3/16/22. Their orientation completed on 3/9/22 did not include prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Human Resources contacted the Staffing Agency and requested training covering prevention, detection and reporting of abuse, suspected abuse, and alleged abuse training for Temporary Direct Service Worker #4. It was communicated these trainings must be completed for Temporary Direct Service Worker #4 to continue to be assigned to work for Milestone Centers. Human Resources will be responsible for ensuring the training materials meet regulatory compliance. |
04/28/2023
| Implemented |
| 6400.51(b)(3) | Temporary Direct Service Worker #4's date-of-hire is 3/16/22. Their orientation completed on 3/9/22 did not include individual rights. | The orientation must encompass the following areas: Individual rights. | Human Resources contacted the Staffing Agency and requested documentation for individual rights training for Temporary Direct Service Worker #4. It was communicated this training must be completed for temporary Direct Service Worker #4 to continue to be assigned to work at Milestone Centers. Human Resources will be responsible for ensuring the training materials meet regulatory compliance. |
04/28/2023
| Implemented |
| 6400.52(a)(1) | Temporary Direct Service Worker #3 completed 21 hours of training during the 2022 annual training year. The OSHA training form that completed 10/3/22 does not include the number of hours of the training, therefore compliance cannot be measured. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Human Resources contacted the Staffing Agency and requested clarification of the number of training hours for the OSHA training form dated 10/3/2022 and for Fire Safety and Abuse/Neglect training. Staffing Agency clarified the number of training hours via email the Temporary Direct Service Worker #3 received. (Staffing Agency clarification attached) Temporary Direct Service Worker #3 completed a total of 24 training hours in 2022. |
03/15/2023
| Implemented |
| 6400.52(c)(1) | Temporary Direct Service Worker #3's 2022 annual training did not include application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships training. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Human Resources contacted the Staffing Agency and requested documentation for application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships training for Temporary Direct Service Worker #3. It was communicated these trainings must be completed for Temporary Direct Service Worker #3 to continue to be assigned to work for Milestone Centers. Human Resources will be responsible for ensuring training meets regulatory compliance. |
04/28/2023
| Implemented |
| 6400.52(c)(3) | Temporary Direct Service Worker #3's 2022 annual training did not include individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Human Resources contacted the Staffing Agency and requested documentation for individual rights training for temporary Direct Support Worker #3. It was communicated this training must be completed for Temporary Direct Support Worker #3 to continue to be assigned to work at Milestone Centers. Human Resources will be responsible for ensuring the training materials meet regulatory compliance. |
04/28/2023
| Implemented |
| 6400.52(c)(5) | Program Specialist #2's 2022 annual training record did not include behavioral supports training specific to the individual(s) being supported. Temporary Direct Service Worker #3's 2022 annual training record did not include a behavioral supports training specific to the individual(s) being supported. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | An updated training record was completed for the Program Specialists to track their ISP trainings in addition to behavior support plans, crisis plans, and any other client specific trainings on 3/17/23. |
03/17/2023
| Implemented |
| 6400.52(c)(6) | Program Specialist #2's 2022 annual training record did not include individual plan training specific to the individual(s) being supported. Temporary Direct Service Worker #3's 2022 annual training record did not include individual plan training specific to the individual(s) being supported. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | An updated training record was completed for the Program Specialists to track their ISP trainings in addition to behavior support plans, crisis plans, and any other client specific trainings on 3/17/23. An updated ISP training record was also created for Temp DSPs. |
03/17/2023
| Implemented |