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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 11:25AM on 3/6/2024, Individual #1's bedroom had a very strong, foul odor. When the bedroom door opened, Medical Coordinator #1 stated "Whew, That's strong" When the licensing representative stepped forward to enter the bedroom, there was a very strong urine smell that made it difficult to breathe. The smell was so strong that Medical Coordinator #1 opened the bedroom window to allow fresh air into the room to make the smell more bearable. Medical Coordinator #1 stated that Individual #1 has incontinence issues and frequently soils the bed. The mattress has plastic cover; however, there is carpet in the bedroom. Medical Coordinator #1 stated that the urine will often go onto the floor and soak into the carpet. | Clean and sanitary conditions shall be maintained in the home. | The carpet in Individual #1¿s bedroom has been removed and the floor was sanitized, sanded down and sealed. |
04/15/2024
| Not Implemented |
| 6400.32(h) | At 11:20AM on 3/6/2024, cameras were observed in the dining room and living room of the home. The agency did not have a current videography recording and retention policy and individuals #1 and #2 had not signed videography consents. | An individual has the right to privacy of person and possessions. | In order to correct this violation a Videography Policy and Consent form has been developed to ensure compliance with privacy regulations and to obtain explicit consent from individuals regarding videography in their living spaces. Individual #1 has now signed the Videography Policy and Consent form, and a copy has been placed in both the home and the client file for reference. |
04/15/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | Written documentation for the 2019 furnace inspection and cleaning was not kept. | 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.
| Family Services United (FSU) recognized the importance of PA Code 6400.106 - 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. [Combustible and flammable materials can be ignited by heat sources, leading to explosions and fires.] Annual furnace inspections promote safety and well-being for individuals residing in the home. Although FSU was able to provide images of the furnace tags for 2019 and 2020 via SharePoint for each home, the documentation for 2019 could not be produced. |
04/22/2021
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 5/1/2020, did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual #1 had an assessment completed on 5/1/2020 that did not include recommendations for specific training, programming, and services. The program specialist received conflicting training guidance from predecessor. To correct this violation, Family Services United (FSU) has retrained the program specialist to complete the assessment in its entirety and updated the program specialist job description. Immediately, the assessment for individual #1 was updated on 4/27/2021 to include recommendations per regulation 6400.181(e)(12) and emailed to the team on 4/27/2021. To prevent the recurrence of this violation, FSU will require the program specialist to submit the annual assessment to the residential director for review of compliance and accuracy. This check will be used when completing current and future assessments for all individuals. The residential director shall review assessments to ensure assessments are completed timely and include required information. Documentation of reviews by the residential shall be maintained. |
04/27/2021
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 2/24/2021. The rights document did not include the following rights: 6400.32b, an individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of his choice and practice no religion; 6400.32e, the right to make choices and accept risks; 6400.32g, to control his own schedule and activities; 6400.32j, the right to voice concerns about the services the individual receives; 6400.32k, the right to participate in the development and implementation of the individual plan; 6400.32L, the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the individual's bedroom door; 6400.32s, to have a key, access card, keypad code or other entry mechanism to lock and unlock entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.[Repeat violation 3/4/2020] | 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. | Family Services United (FSU) recognizes the importance of regulation 6400.34(a) [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]. As an agency we will ensure that individuals are educated on their rights per regulation. Individual #1 was informed and received explanation of individual rights on 2/24/2021. The state representative received the signature pages only. The agency emailed the additional pages on 4/30/2021. The FSU admission packet was updated on 2/20/2021 to include all the rights listed in regulation 6400.34. Individual #1 and all other individuals residing at FSU signed the updated rights on 2/24/2021 in which the state representative received copies of signature pages for sample individuals via SharePoint. |
02/24/2021
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment, completed 5/1/2020 to the individual plan team members for an individual plan meeting on 5/27/2020. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Family Services United (FSU) will ensure that assessments are submitted within the specified timeframe per regulations to the entire team. Program Specialist is responsible for submitting the assessment to the team at least 30 days prior to an individual plan meeting. FSU program specialist will discuss with team that ISP meetings will be scheduled at least 30 days after the anniversary dates. Residential director will oversee the entire process to ensure compliance is met. The assessment 30-day window will be placed on the residential director and program specialist calendar as a reminder. The residential director conducted a training refresher with program specialist on April 23,2021. Immediately, the residential director, or designee, shall train all staff responsible for completing any portion of the individual assessment, coordinating the completion of any portion of the assessment, or ensuring the completion of the individual assessment on the required components of an individual assessment, including required content and timelines, as indicated by 6400.181(a-f). Documentation of training shall be kept. |
04/23/2021
| Implemented |
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