| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/26/22 to 12/26/22, and the self- assessment was completed on 1/10/23. This exceeds the requirement. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Community Resources for Human Services (CRHS) management will ensure self-assessments are completed in each serving home within 3-6 months prior to the expiration date of the certificate of compliance to measure and record compliance. |
03/30/2023
| Implemented |
| 6400.65 | Bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The downstairs bathroom located near the kitchen did not have a window or mechanical ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Downstairs Bathroom was repaired and a new ventilation system installed immediately to correct the violation. |
03/16/2023
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination dated 12/2/22 did not include Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control as this section of the exam was left blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1 immunizations were printed and attached to the physical form completed on 12/2/22. The immunizations will be attached to the all the physical forms moving forward. |
03/13/2023
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination dated 12/2/22 did not include an assessment of the individual's health maintenance needs as this section of the exam was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Individual #1 physical form dated 12/22/22 is to be revised by the provider to document the health maintenance needs. The form was resubmitted to the Dr. |
03/14/2023
| Implemented |
| 6400.151(c)(3) | Staff #1's physical examination dated 6/17/22 did not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff #1 completed a new physical on 3/16/23. Staff #1 submitted the correctly filled out form to the agency which complies with the regulations. |
03/15/2023
| Implemented |
| 6400.52(a)(3) | There is no documentation that Staff #1 completed 24 hours of training in the training year 7/1/21-6/30/22. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | Community Resources for Human Services (CRHS) human resource department will ensure all CRHS staff shall complete 24 hours of training related to job skills and know each year for compliance. Staff #1 is to complete 24hr of training related to Program specialist role for the current year in before 6/30/23. |
03/20/2023
| Implemented |
| 6400.52(c)(1) | There is no documentation that Staff #1 received annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships in the training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #1 has completed all the mandated annual training in the application of person-centered practices, community integration, individual rights and supporting individuals to develop and maintain relationships for the current training year. 7/1/22-6/30/23 |
03/20/2023
| Implemented |
| 6400.52(c)(2) | There is no documentation that Staff #1 received annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in the training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) 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. | Staff #1 has completed the annual training in the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse for the current training year. 7/1/22-6/30/23 |
02/24/2023
| Implemented |
| 6400.52(c)(3) | There is no documentation that Staff #1 received annual training in Individual rights in the training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #1 has completed the annual training in Individual Rights for the current training year. 7/1/22-6/30/23 |
01/31/2023
| Implemented |
| 6400.52(c)(4) | There is no documentation that Staff #1 received annual training in recognizing and reporting incidents in the training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff #1 has completed the annual training in Recognizing and Reporting Incidents for the current training year. 7/1/22-6/30/23 |
02/24/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's Mediation Administration Record (MAR) did not include the diagnosis or purpose for the following medications: Essentialzyme, Takesumi Supreme, Calcerea Carbonica, Ningxia Red, Lemon Essential Oil, Endoflex Essential Oil, Calcarea Floorica, Wheatgrass, Young Living Mineral Sunscreen, Red Drink, Vitamin D3 5000, Detoxzyme, ICP, Parafree, Comfortone, Megasspore, Sodium Ascorbate, Super B, and Sulfzurzyme. | 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. | Individual #1 MAR have been revised to state all the diagnosis. The individual's doctor re-submitted documentation with correct diagnosis for each medication. |
03/17/2023
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan (ISP) states that they do not understand the value of money. Individual #1 needs support to differentiate between coins and bills. Individual #1's assessment dated 1/20/2023 states under the financial sections that Yes they are able to safely carry $50.00, and their skill code level is indicated with a 5 as being independent. Under Individual #1's performance, progress, and growth in the area of finances it states that Individual # 1 is unable to manage his own finances. The individual plan shall be revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | CRHS Program Coordinator revised the assessment to match the ISP after the team meeting. The current assessment was revised to explain the individual being able to carry the funds but under staff supervision at all times. The skill level was also revised and documented appropriately. |
03/14/2023
| Implemented |