| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.145(1) | Individual #1's current emergency medical plan dated August 2020 states that the hospital or source of health care that will be used in an emergency is Lancaster General 555 N. Duke St. Lancaster, PA 17602. Individual #1's emergency medical documentation states that their preferred hospital is Ephrata Hospital. The Emergency Medical Plan does not reflect the Individual's preferred hospital. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | b. Plan of Correction
i. Plan to correct immediate problem
1. Who?
a. , Program Specialist
2. What will be corrected?
a. Emergency Medical Plan will be updated to reflect individual preference for hospital.
3. When and How?
a. Emergency Medical Plan for home/individual was updated on 3.13.2024 to include person-centered information pertaining to choice of preferred hospital. |
03/25/2024
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment dated 11/9/2023 states that they do not have any pysch evaluations on file. However, there is a psychiatric evaluation on file dated 6/20/2007 for Individual #1. | The assessment must include the following information: Psychological evaluations, if applicable. | b. Plan of Correction
i. Plan to correct immediate problem
1. Who?
a. , Program Specialist
2. What will be corrected?
a. Assessment will be reflective of the accurate information at the time for the individual within supports.
3. When and How?
a. Program Specialist sent out addendum to ISP Team with updated information so that information in assessment matches current information pertaining to the individual.
b. This was completed on 3.14.2024 |
03/25/2024
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's current assessment dated 11/9/2023 states that they require assistance managing money and finances. Staff are not tracking finances. During discussion it was stated that the Individual receives $40/week from their rep payee on a debit card and is capable of spending how they choose. The specific financial independence in which Individual #1 is capable of needs to be recorded in the assessment accurately. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| i. Plan to correct immediate problem
1. Who?
a. , Program Specialist
2. What will be corrected?
a. Assessment will be updated with the correct, most up to date information pertaining to the individual¿s financial independence at the current time.
3. When and How?
a. Program Specialist completed an addendum to the Assessment on 3.14.2024 to reflect the most current information and needs of the individual within supports. |
03/25/2024
| Implemented |
| 6400.211(b)(1) | Individual #1's emergency contact does not include their address. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| b. Plan of Correction
i. Plan to correct immediate problem
1. Who?
a. , Program Specialist
2. What will be corrected?
a. Emergency Contact on the Emergency Medical Plan will include the address of the Emergency Contact.
3. When and How?
a. This was corrected on 3.13.2024 by Program Specialist for this individual and home |
03/25/2024
| Implemented |
| 6400.182(c) | Individual #1's current ISP dated 2/12/2024 states that residential staff will assist with keep a ledger to track financial transactions. Residential staff are not currently keeping a financial ledger for Individual #1. During discussion it was stated that the Individual receives $40/week from their rep payee on a debit card and is capable of spending how they chose. The current financial independence of which Individual #1 is capable of needs to be recorded in the ISP accurately. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | b. Plan of Correction
i. Plan to correct immediate problem
1. Who?
a. , Program Specialist
2. What will be corrected?
a. Individual¿s ISP will be reflective of current financial needs for the individual in supports.
3. When and How?
a. Program Specialist sent correspondence to Supports Coordinator with updates needed in the ISP to reflect the current status of individual¿s financial status. Program Specialist received response on 3.14.24 with updated information to reflect current status of individual¿s needs. |
03/25/2024
| Implemented |
| 6400.183(a)(3) | Individual #1's annual ISP meeting held on 7/19/2023 does not include a direct care staff person. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | b. Plan of Correction
i. Plan to correct immediate problem
1. Who?
a. , Program Specialist
2. What will be corrected?
a. Faithful Homes will have DSP¿s sign off on attendance to ISP meetings
b. Faithful Homes will update assessment form to indicate that DSP¿s also have input into the assessment and ISP meetings.
3. When and How?
a. DSP¿s signing off on ISP attendance will take effect immediately on 3/14/2024 and ongoing.
b. Assessment template will be updated by 4/1/2024 to include information about DSP input to create assessment and input for the ISP. |
03/26/2024
| Implemented |