Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | Floors, walls, ceilings, and other surfaces shall be in good repair. At the time of inspection, there were 6 separate sections of the beige tile of the kitchen counter edges that were cracked. The sections ranged from being cracked in section of approximately 1 inch to up to 8 inches. | Floors, walls, ceilings and other surfaces shall be in good repair. | A work order was submitted in MaintainX for maintenance to determine if the countertop can be repaired or is it has to be replaced. |
10/18/2023
| Implemented |
6400.81(k)(6) | Individual #1 did not have a mirror in their bedroom, and it was not documented in their Individual Support Plan that they did not want to have one. | In bedrooms, each individual shall have the following: A mirror. | Futures will purchase a mirror. |
10/20/2023
| Implemented |
6400.141(c)(14) | Individual #1's physical examination dated 2/1/23 did not include medical information pertinent to diagnosis and treatment in case of an emergency as this section of the examination was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialist will review all annual physicals before they are uploaded to agency eHR. If any information is missing the physician will be contacted. |
10/18/2023
| Implemented |
6400.32(r) | An individual has the right to lock the individual's bedroom door. Individual #1 did not have a lock on their bedroom door. | An individual has the right to lock the individual's bedroom door. | Futures will communicate with all individuals and guardians who have opted to not have locks on their bedroom doors in an effort to help them make informed decisions. Futures will recommend all doors have locks on them and ensure all parties that staff will have a key on their person in case of emergency. If the person or guardian are adamant, they do not want a lock then the program specialist will request the ISP be updated. |
10/31/2023
| Implemented |
6400.51(b)(1) | Staff #1's did not receive orientation training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Staff #1's date of hire is 4/18/23 and they did not receive training until 5/23/23 and 6/5/23 in the training area. | 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. | Orientation training is scheduled by our training coordinator upon hire and communicated with the program manager and program specialist. Communication is provided to the program manager and program specialist. The training coordinator notifies both when a staff did not attend their scheduled training.
The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled.
If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. |
11/14/2023
| Implemented |
6400.51(b)(2) | Staff #1's did not receive orientation training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Staff #1's date of hire is 4/18/23 and they received training on 6/5/23 in the training area. | 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. | The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled.
If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. |
11/14/2023
| Implemented |
6400.51(b)(3) | Staff #1's did not receive orientation training on Individual rights during orientation training. Staff #1's date of hire is 4/18/23 and they did not receive training until 5/23/23 in Individual Rights. | The orientation must encompass the following areas: Individual rights. | The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled.
If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. |
11/14/2023
| Implemented |
6400.51(b)(4) | Staff #1's did not receive orientation training on recognizing and reporting incidents. Staff #1's date of hire is 4/18/23 and they did not receive training on recognizing and reporting incidents until 5/26/23 and 6/5/23. | The orientation must encompass the following areas: recognizing and reporting incidents. | The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled.
If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. |
11/14/2023
| Implemented |
6400.181(f) | Individual #1's annual assessment was completed on 2/1/23, and there is no record or documentation that the program specialist provided the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program specialist will submit the assessment via email and/or with a cover letter which will include the date of the submission. |
08/29/2022
| Implemented |