Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(13) | For individual 1 - the allergies section of the January 2024 physical is blank. | The physical examination shall include: Allergies or contraindicated medications. | On April 1, 2024, the agency's nurse rectified an oversight by addressing the blank allergies section in the January 2024 physical for Individual 1. |
04/01/2024
| Implemented |
6400.181(c) | For individual 1 - the 2022 and 2023 assessments appear to be identical in their contents. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | On March 27, 2023, the Chief Operating Officer (COO) conducted an orientation for the Program Specialist (PS) and identified similarities in both annual assessments. |
03/27/2024
| Implemented |
6400.181(e)(3)(i) | For individual 1 - the assessment does not speak to the individual's progress in areas that support is needed (for example, the reported desire/objective to become self-medicating). | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | On March 27, 2023, the Chief Operating Officer (COO) oriented the Program Specialist (PS) to ensure that assessments reflect the individual's progress in areas where support is needed. |
03/27/2024
| Implemented |
6400.181(e)(12) | For individual 1 - the assessment does not provide any details regarding recommendations for areas of training, programming, or services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | On March 27, 2023, the Chief Operating Officer (COO) oriented the Program Specialist (PS) to ensure that assessments provide detailed recommendations for areas of training, programming, or services. |
03/27/2024
| Implemented |
6400.32(r) | The individual rights form does not include stipulation about the consumer's right to have a lock on their door. | An individual has the right to lock the individual's bedroom door. | The bedrooms lack the proper door locks per regulation 55 PA Code Chapter 6400.32(r) regarding an individual's right to lock their bedroom door. In compliance with this regulation, Halia's maintenance team addressed these issues on March 28, 2024, by installing the proper door locks on all bedroom doors, granting individuals the right to secure their private spaces. |
04/01/2024
| Implemented |
6400.186 | For individual 1 - the provided documentation (ISP, monthly progress notes, assessment) all indicate that the individual continues to present challenging behaviors. Such behaviors were identified for treatment in the BSP included in his file. The BSP treatment plan date ended 5/13/23, which is outdated based on included data, and requires renewal to enact his plan and meet his needs as dictated. | The home shall implement the individual plan, including revisions. | On March 27, 2023, the Chief Operating Officer (COO) oriented the Program Specialist (PS) to ensure that the Behavioral Support Plan (BSP) treatment plan, which ended on May 13, 2023, has been updated by the behavioral specialist to ensure its renewal and alignment with the individual's needs as prescribed. |
03/27/2024
| Implemented |