| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | Furnace inspection reports were not provided during the inspection, making it impossible to determine if it had been cleaned annually as required. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| PCS have always relied on the annual certificate of occupancy from our land-law for assurance that the furnaces inspected. We are now in contract with a reputable heating and cooling company to inspect and document furnace maintenance going forward. Our CEO will ensure PCS is in compliance going forward. |
11/21/2023
| Implemented |
| 6400.111(a) | The fire extinguisher on the top floor of the home did not meet the minimum 2A rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The small portable fire extinguisher was replaced with a larger compliant one the day after the review. |
11/22/2023
| Implemented |
| 6400.113(a) | There is no documentation that individual 2 received fire safety training in the past year. | 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. | PCS is committed to ensuring all individuals in our program are trained on fire-safety per the regulars. This violation was an oversight. |
11/21/2023
| Implemented |
| 6400.141(c)(4) | 400 days have elapsed between the 5/5/2022 and 6/8/23 annual vision appointments for individual 2, which exceeds the 365 day/annual requirement. At the 11/23/22 annual physical, the primary care physician recommended that the individual have further evaluation by a specialist for a hearing screening. There is no documentation that an appointment with a hearing screening with a specialist occurred or was scheduled. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual 2 does not comply with vision examinations. |
11/24/2023
| Implemented |
| 6400.141(c)(10) | The 11/23/22 annual physical for individual 2 does not indicate if the individual is free of communicable disease and/or any precautions that need to be taken. In the section of the form designated for this purpose, both the yes and no boxes are blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | In an attempt to redo the annual physical, we are told that the insurance company would not approve
another physical until the next circle. |
10/21/2023
| Implemented |
| 6400.181(e)(7) | The assessment for individual 2 does not specify whether the individual can sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | PCS have reached out to individual @ support coordinator, PCP and psychiatrist for an assessment. An assessment is scheduled for 03/14/2024 |
11/18/2023
| Implemented |
| 6400.181(e)(13)(iii) | The 9/22/23 annual assessment for Individual 2 contains information in various areas that is old, referring to last year as 2019 for example. There is also another individual's name indicating information from the assessment had been cut and pasted from another individual's assessment. This error was duplicated from the prior year's assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | An update of the assessment was completed 11/30/2023 |
11/30/2023
| Implemented |
| 6400.52(a)(1) | The training hours for Staff 2 are less than the required 24hrs, based on the reported calendar training year (2022 being assessed). | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | PCS is committed to full compliance of 24 hours training of all staff in the next training circle. We plan to be guided by the regulations in PA 6400. |
11/30/2023
| Implemented |
| 6400.52(c)(1) | The provided CEO training hours indicate that a 24hr course titled "developmental disabilities & sexuality" was completed July 2023. This provided training does not fall within the inspected training timeline (2022 calendar year). This training certificate is not comprehensive as the regulation outlines, which should include person-centered practices, community integration, prevention & detection of abuse, individual rights, recognizing and reporting incidents, etc. (point c, subpoints 1-6). | 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. | PCS will, going forward follow and keep up-to-date with PA 6400 Regulations to ensure training compliance. The CEO completed more than 24 hours of trainings in the review period but according to the regulations those trainings were not specific to the ones outlined in the regulations . |
11/30/2023
| Implemented |
| 6400.181(f) | For Individual 2, there is no letter from the program specialist providing the assessment to the individual plan team members at least 30 calendar days prior to the 4/10/23 individual plan 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. | While we believe this was done and complied with., we could not find the email to show compliance. We are however committed to complying with this regulation as we are with all others. |
11/30/2023
| Implemented |
| 6400.213(1)(i) | The record for Individual 2 does not include a current dated photograph. The photograph in the record is dated 9/20/2017 and needs to be updated annually. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Record book furnished with current photograph of individual 2. |
11/10/2023
| Implemented |