| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(a) | The initial assessment for Individual #2 was not completed within 60 days of admission. Individual #2 was admitted on 8/03/2021 and the initial assessment was not completed until 12/06/2021. | 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. | director of residential, program coordinator were retrained on the initial assessments due dates and time frame for completion. |
06/06/2022
| Implemented |
| 6400.181(e)(12) | There were no recommendations for specific areas of training, programming and services for Individual #2 in the initial assessment. Instead, the author of the assessment included recommendations for the staff rather than the individual. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program coordinator and Director of Residential were retrained on the content and due dates of the initial assessments and the importance of including client recommendations for specific training, programming and services for all individuals. Individual #2 plan has been updated to reflect recommendations for specific areas of training, programming and services . |
06/06/2022
| Implemented |
| 6400.15(b) | The self-assessment completed for Levering Place was not completed on the correct Department form. The form that the provider used was an outdated form and did not contain the current, updated 6400 regulations. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Management staff ( director of residential , allentown , and program coordinator ) were trained on the correct self-assessment that needed to be completed. |
05/30/2022
| Implemented |
| 6400.32(r)(4) | The lock on Individual #2's bedroom door was a "pinhole" type locking mechanism and there was no tool available to allow immediate and easy access for individual or staff in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Individual #2 lock was replaced with a bedroom door lock that allowed for easy access for individual or staff in the event of an emergency.
Staff (program coordinator and direct care) were retrained on the importance of having an appropriate lock on an individual's door. |
05/30/2022
| Implemented |
| 6400.34(a) | Individual #2 was informed of her rights but the rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include the individual shall not be deprived of rights. shall not receive punishment or retribution for exercising their rights, civil and legal rights, individual shall be treated with dignity and respect, the individual shall have the ability to make choices and accept risks, the right to refuse activities, the right to control their schedule, the right to access their possessions and security of possessions, the right to voice concerns, the right to choose a roommate, the right to furnish and decorate bedrooms and common areas, locking mechanism, access to bedroom, assistive technology, immediate access, direct service workers shall have the key or entry device to lock and unlock the door, and an individual's right may only be modified in accordance with § 6400.185 (relating to content of individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others, the right to access food, make healthcare decisions, and resolving differences. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual #2 had the clients' rights reviewed with them and signed an updated copy of the right that reflect the current chapter 6400 regulations. Staff Program coordinator and Director of Residential were trained on the current client rights and all rights that should be included and time frame which it should occur. |
05/30/2022
| Implemented |
| 6400.165(g) | Individual #2 is prescribed the medication LEVETIRACETAM to treat the symptoms of bipolar disorder. The individual's primary care physician (PCP) has been reviewing the medication but there was no documentation completed and signed by the doctor to indicate the medication(s), dosage of medication(s), and the need to continue the medication(s). | 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. | Individual #2 as a follow up went to her PCP in order to get clarity on why Levetiracetam (Keppra) was prescribed. PCP remarks included the following ¿Keppra is being prescribed for a seizure disorder, she is not on any psychotropic medication.¿ Currently the medication is being used for a management of seizure disorder. Staff was retrained on reviewing medications and diagnosis and ensuring that proper er follow up is made psychotropic meds identified/use for behavior management symptoms related to a psyche diagnosis. |
05/05/2022
| Implemented |