| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #2 had a physical on 10/10/19 and their 2020 annual physical was completed on 10/28/20 which exceeds the annual timeframe. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The agency has communicated to the PCP the necessity of providing these Annual Physicals in a timely fashion, despite cancellations. We have requested to have the Individual be examined by an alternate physician in the event the regularly scheduled examiner is unexpectedly unavailable and cancels his/or her own visit with that Individual. |
05/18/2021
| Implemented |
| 6400.141(c)(6) | Individual #2 had a tuberculin skin testing by Mantoux on 10/9/18 with a negative result and their next one was completed on 10/28/20 which exceeds the 2 year requirement. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The agency has communicated to the PCP the necessity of providing these Annual Physicals for examinations and treatments and specifically Tuberculin Skin Testing by Mantoux Method to be in a timely fashion, despite cancellations. We have requested to have the Individual be examined by an alternate physician in the event the regularly scheduled examiner is unexpectedly unavailable and cancels his/or her own visit with that Individual. |
05/18/2021
| Implemented |
| 6400.144 | Individual #2 had an audiology appointment on 11/13/19 and it noted to follow up in on one year. There is no documentation that this occurred. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The agency had the PCP screen the individual for Vision and Hearing due to the Covid-19 cases medical appointments had been limited in availability.
This examination will take place as required and the agency ensures this is corrected moving forward. |
05/18/2021
| Implemented |
| 6400.46(b) | Staff #1 and Staff #2 both received fire safety training on 4/3/19, and then not again until 5/6/2020. This exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff #1 and Staff #2 have been apprised of the necessity to comply with scheduled trainings in a timely fashion. Our Staff Training monitor has reviewed and been apprised of the need to schedule trainings and reminders in a timely fashion. |
05/18/2021
| Implemented |
| 6400.52(c)(1) | Staff #1 did not receive annual training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the April 2019-June 2020 timeframe. | 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. | Staff #1 has been apprised of the necessity to comply with scheduled trainings in a timely fashion. Our Staff Training monitor has reviewed and been apprised of the need to schedule trainings and reminders in a timely fashion. Specifically to the training for the application of Person Centered Practices, Community Integration, Individual Choice and supporting individuals to develop and maintain relationships. |
05/18/2021
| Implemented |
| 6400.52(c)(2) | Staff #1 did not receive annual training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse April 2019-June 2020 timeframe. | 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. | Staff #1 has been apprised of the necessity to comply with scheduled trainings in a timely fashion. Our Staff Training monitor has reviewed and been apprised of the need to schedule trainings and reminders in a timely fashion. Specifically to the training for the annual training for the Prevention, Detection and Reporting of Abuse, Suspected Abuse and Alleged Abuse. |
05/18/2021
| Implemented |
| 6400.52(c)(3) | Staff #1 and Staff #2 did not receive annual training on individual rights during the April 2019-June 2020 timeframe. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #1 and Staff #2 have been apprised of the necessity to comply with scheduled trainings in a timely fashion. Our Staff Training monitor has reviewed and been apprised of the need to schedule trainings and reminders in a timely fashion. Specifically to the training with regard to the annual training for Individual Rights. |
05/18/2021
| Implemented |
| 6400.52(c)(4) | Staff #1 did not receive annual training on recognizing and reporting incidents during the April 2019-June 2020 timeframe. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff #1 has been apprised of the necessity to comply with scheduled trainings in a timely fashion. Our Staff Training monitor has reviewed and been apprised of the need to schedule trainings and reminders in a timely fashion. Specifically to the training for the annual training on Recognizing and Reporting Incidents. |
05/18/2021
| Implemented |
| 6400.52(c)(5) | Staff #1 and Staff #2 did not receive annual training on the safe and appropriate use of behavior supports during the April 2019-June 2020 timeframe. | 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. | Staff #1 and Staff #2 have been apprised of the necessity to comply with scheduled trainings in a timely fashion. Our Staff Training monitor has reviewed and been apprised of the need to schedule trainings and reminders in a timely fashion. Specifically to the training for the annual training on Safe and Appropriate use of Behavior Supports. |
05/18/2021
| Implemented |
| 6400.52(c)(6) | Staff #1 and Staff #2 did not receive annual training on the implementation of the individual plan during the April 2019-June 2020 timeframe. | 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. | Staff #1 and Staff #2 have been apprised of the necessity to comply with scheduled trainings in a timely fashion. Our Staff Training monitor has reviewed and been apprised of the need to schedule trainings and reminders in a timely fashion. Specifically to the training for the annual training of each Individual's Plan. |
05/18/2021
| Implemented |