| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The kitchen cabinets are missing knobs. | Floors, walls, ceilings and other surfaces shall be in good repair. | The provider has replaced the missing knobs in the kitchen cabinets. The Provider will ensure that all its sites moving forward would be in good repair with no missing kitchen cabinets knobs and no structural damages on floors, walls and ceilings at all its sites, to maintain compliance according to PA Code Chapter 6400.67(a) |
10/28/2022
| Implemented |
| 6400.112(d) | Nearly all fire drill records provided show evacuation times that exceed two and a half minutes. Extended evacuation time documentation was requested but not provided. For all drills submitted for the months of January 2022 to August 2022 have evacuation times that exceed 2.5 minutes, except for 5/16/22, which was 2 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A staff meeting was held on August 26 2022 wherein the Q.I Specialist trained staff on conducting Fire Drill while we await a date by the Fire Safety Safety Expert. Moving forward, all staff on duty at our respective sites, would ensure that our individuals evacuate the homes during fire drills within given time frames to remain in compliance with the regulation.. |
08/26/2022
| Implemented |
| 6400.113(a) | Individual #3 has not received annual fire safety trainings. Their most recent training is dated 3/20/19. They also did not receive new fire safety training upon moving on 2/3/22. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Individual # 3 was to be trained after her hospital stay, but unfortunately she never made it home. She passed. |
11/09/2022
| Implemented |
| 6400.144 | Agency records do not indicate that health services are being adequately provided for Individual #3. The most recent documented physical was on 6/12/20. There are no records of dental, OB/GYN, or hearing exams in their file. Their most recent vision exam in agency records is dated 11/19/19. The individual has had extensive hospitalizations during their time in the agency; records of these hospitalizations and any exams completed while in the hospital were requested but not provided. | 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.
| During Individual # 3 stay with the Agency, numerous team meetings were held to discuss her non compliance to attend appointments and get appropriate treatments. She was mostly hospitalized during the time she was with agency.We have filed and closed out about 20 hospitalizations in EIM on individual # 3. Moving forward, the Program Specialist would have maintain proper documentation on Individual # 3 medical treatment refusals but unfortunately, had passed on. |
11/09/2022
| Implemented |
| 6400.144 | PRN medication for Ind. #4 is listed on the MAR but not present on site in individuals medication box. | 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.
| Moving Forward, Provider would ensure that PRN medication for this individual as listed on the MAR is kept in medication Box at all times to maintain compliance with the regulation. ( Provider is not aware of who Individual # 4 is, nor the name of the PRN Medication) |
11/09/2022
| Implemented |
| 6400.181(a) | Greater than one year elapsed between Individual #3 two most recent annual assessments, dated 1/7/21 and 2/8/22. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Program Specialist would ensure individual # 3 annual assessment is done in a timely manner to be compliant according to PA Code Chapter 6400.181(a) |
11/09/2022
| Implemented |