| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.49(c)(1) | Chief Executive Officer #1 annual trainings for the training year 12/1/2021 through 11/30/2022 did not encompass the application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships. | 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. | Chief Executive Officer #1 will complete trainings outlined in subsections (a) and (b) that encompass the application of person-centered practices, community integration, client choice, and supporting clients to develop and maintain relationships that were incomplete at the time of training. All other administrative staff will complete the 12 hours of training outlined in 55 PA Code Chapter 2390.49 (c) (1-5). Chief Executive Officer #1 and all other administrative staff will be added to the training calendar to ensure these trainings take place on an annual basis |
08/30/2023
| Implemented |
| 2390.49(c)(3) | Chief Executive Officer #1 annual trainings for the training year 12/1/2021 through 11/30/2022 did not encompass client rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights. | Chief Executive Officer #1 will complete trainings outlined in subsections (a) and (b) that encompass the application of person-centered practices, community integration, client choice, and supporting clients to develop and maintain relationships, and client rights that were incomplete at the time of training. All other administrative staff will complete the 12 hours of training outlined in 55 PA Code Chapter 2390.49 (c) (1-5). Chief Executive Officer #1 and all other administrative staff will be added to the training calendar to ensure these trainings take place on an annual basis. |
09/15/2023
| Implemented |
| 2390.152(c) | Individual #1's assessment, completed 1/14/2022, was sent to plan team members on 1/14/2022 for the Individual Service Plan meeting annual meeting held on 8/15/2022. The assessment was not reviewed and sent to the plan team within six months prior to the Individual Service Plan meeting. Individual #2's assessment, completed 1/10/2022, was sent to plan team members on 1/10/2022 for the Individual Service Plan meeting held on 12/14/2022. The assessment was not reviewed and sent to the plan team within six months prior to the Individual Service Plan meeting. | The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment. | Program specialist will review the annual assessments for Individual #1 and Individual #2 and make any necessary updates or changes. These updated assessments for both Individual #1 and Individual #2 will be emailed/sent to all team members so that everyone has a current copy of the assessment. Program Specialist will keep and print a copy of the email sent in order to document the review was complete. |
09/15/2023
| Implemented |