| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 (Joe) is prescribed a PRN medication, the generic form of Mirlax) "Polyeth Glyc Pow 3350 NF", 17 GM/Scoop powder for constipation.
At the time of the inspection, the PRN medication for constipation was not found in the home. | 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.
| PRN that was found not in compliance during the annual review is now located in the home. All medications in each of the homes was conducted and no other issues was found. |
08/02/2023
| Implemented |
| 6400.181(d) | At the time of the inspection, the annual assessment dated 7/17/2023 that was located in individual #1's program book was not signed and dated by the Program Specialist. | The program specialist shall sign and date the assessment. | All assessments have been reviewed and any that was noted to be out of compliance was reviewed and updated by the CEO, signed and sent to the individual and their team members. |
08/02/2023
| Implemented |
| 6400.44(b)(1) | Individual #1's assessment dated 7/17/23 was completed by staff #2 (Michael Nicolson) who is not qualified to serve in the role of program specialist. | The program specialist shall be responsible for the following: Coordinating the completion of assessments. | The program manager job description has been updated to reflect those job duties that is their responsibility and ensuring that no job duty is listed that is a program specialist job, outlined in the 6400 regulations.
All assessments have been reviewed for compliance and any noncompliance has been corrected and sent to the team members as well as the individual. |
08/02/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's MAR for May 2023 contained medication "Prednisone TAB 20MG" but it did not indicate the diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The MAR that did not contain this information has been updated to reflect the diagnosis/purpose.
All MAR's have been reviewed by the medical department and no other non-compliance was noted. |
08/02/2023
| Implemented |
| 6400.181(f) | At the time of the inspection, there was no documentation showing that the assessment was sent to the team plan members 30 days prior to the ISP meeting date (2/15/23). | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | All plans have been reviewed for compliance and have been updated by the CEO to ensure compliance and was sent to the individual and team members. |
08/02/2023
| Implemented |
| Article X.1007 | Staff #4 was hired as a previous out of state employee who now lives in PA on 6/23/23. At the time of the inspection, staff #4 did not have a Pa criminal background check completed or the FBI criminal background check completed. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | During the review the staff that was reviewed no longer works for LCSS. All current staff clearances have been reviewed and no other non compliance was noted. All other staff has been compliant with criminal history checks, including FBI clearances when required. |
08/02/2023
| Implemented |