| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Individual 1 bedroom door has a large gash carved into it that was taped over. | Floors, walls, ceilings and other surfaces shall be in good repair. | On September 5, 2023, the Lifetime Skills maintenance crew supervised by the ED completed the repairs to the door making it safe for the individual to navigate freely in his home. |
09/05/2023
| Implemented |
| 6400.72(a) | Individual 1 bedroom window has no screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | On September 5, 2023, Window screen was purchased replacing missing screen in the individual's bedroom.
Plan of Action: In compliance with 55 PA Code Chapter 6400.72(a), Lifetime Skills will continue to conduct routine inspections of the individual's home to ensure all safety aspects are completed. These inspections further demonstrate our desire to improve the quality of our homes. |
10/28/2023
| Implemented |
| 6400.141(a) | No physical provided for calendar year 2022. for individual 1 | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual 1's record recommended yearly vision screening, but no vision screening is in the binder. Lifetime Skills acknowledges this citation and has taken the necessary steps to current this violation by instituting a requested transition checklist. This system is in place as of 8/4/2023. see attachment#11 |
08/04/2023
| Implemented |
| 6400.142(a) | There is no dental record in the file for individual 1. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | On 11/1/2023, the program specialist successfully coordinated a dental appointment for individual 1. This was carried out with the primary objective of maintaining comprehensive documentation pertaining to the dental examination. See Attachment#13 |
10/28/2023
| Implemented |
| 6400.144 | Individual 1 med kit was missing the PRN clonazepam that is listed on their MAR. | 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.
| Lifetime Skills acknowledges the issuance of this citation. However, the appropriate step was taken on August 25, 2023, placing the above-listed medication in the individual med |
08/25/2023
| Implemented |
| 6400.32(r) | Individual rights need to be updated to reflect current changes in individual rights. Signed rights did not include individual 1 has the right to lock his bedroom door. | An individual has the right to lock the individual's bedroom door. | As of 8/4/2023, Lifetime Skills via its program specialist has updated the individual rights to reflect new changes per the 6400 regulations. An updated copy of the individual rights is signed and placed in the individual binder. |
10/28/2023
| Implemented |
| 6400.165(g) | There was no psychotropic medication form completed for the 2022 calendar year for individual 1. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Upon the discovery of Individual #1's missing psychotropic medication reviews, Lifetime Skills has implemented a policy to safeguard the health and safety of all individuals and rectify this violation. This policy ensures that all individuals who are prescribed psychotropic medications undergo quarterly medication reviews, and the documentation for these reviews is maintained in their respective medical binders. |
10/28/2023
| Implemented |
| 6400.181(f) | Individual 1's 2023 assessment was not sent to the plan team 30 days prior to the 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. | Lifetime Skills acknowledges this citation with the necessary recommendations. A current copy of the individual¿s assessment has been submitted to the team for review, signature, and return to form part of the program record. |
10/28/2023
| Implemented |
| 6400.183(c) | Individual 1's record did not have the ISP sign in sheet. | The list of persons who participated in the individual plan meeting shall be kept. | Lifetime Skills welcomes this citation and has requested a copy of the individual ISP signing sheet, which validates that the meeting was held as well as attendance at the meeting. This violation was due to the meeting being held virtually. |
10/28/2023
| Implemented |