| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(a) | Individual #1 had an assessment completed 10/1/21 then again 11/3/22. | Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | This Provider developed a spreadsheet documenting all individuals assessment dates to assure regulatory compliance. |
12/07/2022
| Implemented |
| 2390.49(c)(1) | Direct Service Worker #1 was not trained in the application of person-centered practices, including community integration, client choice and supporting clients to develop and maintain relationships in the training year, from July 1, 2021 to June 30, 2022. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships. | Provide documentation of completed training in the following topics: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships by direct service #1. |
12/07/2022
| Implemented |
| 2390.49(c)(2) | Direct Service Worker #1 was not trained in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, in the training year, from July 1, 2021 to June 30, 2022.. | The annual training hours specified in subsections (a) and (b) 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. | Provide documentation of completed training in the following topics: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act by direct service #1. |
12/07/2022
| Implemented |
| 2390.49(c)(3) | Direct Service Worker #1 was not trained in client rights, in the training year, from July 1, 2021 to June 30, 2022. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights. | Provide documentation of completed training in the following topic: client rights by direct service #1. |
12/07/2022
| Implemented |
| 2390.151(f) | The program specialist provided Individual #1's assessment, completed 11/3/22 to plan team members on 11/3/22 for the individual plan meeting on 11/10/22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | This Provider developed a spreadsheet documenting all individuals assessment dates to assure regulatory compliance. |
12/07/2022
| Implemented |