| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Door track in individual#1's bedroom needs to be repaired as door gets stuck on track. | Floors, walls, ceilings and other surfaces shall be in good repair. | 55 PA Code Chapter 6400.67(a)- Floors, walls, ceilings and other surfaces shall be in good repair.
Biacons maintenance staff will round monthly or as notified by staff of any item not in good repair. Any item that is not in good repair will be fixed or replaced within a week. See attachment M |
02/25/2023
| Implemented |
| 6400.67(b) | Wood railing to side entrance is loose at the base of the staircase and is in need of repair. The loose fence poses a falling hazard.
Wood tread on top step is loose. There is a crack in the joist supporting the step that is in need of repair as these loose planks pose a falling and/or tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | 55 PA Code Chapter 6400.67(b) - Floors, walls, ceilings and other surfaces shall be free of hazards.
Biacons maintenance staff will round monthly or as notified by staff of any item not in good repair. Any item that is not in good repair will be fixed or replaced within a week. see attachment N |
02/25/2023
| Implemented |
| 6400.141(a) | Individual#1 was admitted 9/15/22 did not have a physical completed within 12 months prior to admission, the only physical in the file was completed on 11/8/22 with a tuberculosis test completed in 12/2022. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 55 PA Code Chapter 6400.141(a) - An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
Individual #1 preadmission physical examination was dated 11/4/2021 and his current physical after admission was done on 11/8/22. Biacons Nurse will ensure all consumer have a physical examination within 12 months of admission. A review of each consumers records will be done monthly by the nurse. See attachment O&P |
01/16/2023
| Implemented |
| 6400.141(c)(14) | Individual#1's 11/8/22 physical does not include information pertinent to diagnosis in case of emergency. This line is left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 55 PA Code Chapter 6400.141(c)(14)-The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.
Biacons nurse will review each consumers physical upon receipt and monthly to ensure all areas are accurately filled out by the physician. See attachment O |
03/01/2023
| Implemented |
| 6400.24 | It could not be determined if new hire-staff member #2 was a resident of the Commonwealth prior to employment as both boxes were checked on the residency waiver and FBI check was not completed for this staff member. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | 55 PA Code Chapter 6400.24- The home shall comply with applicable Federal and State statutes and regulations and local ordinances.
Biacons HR will ensure that federal and State statutes and regulations are followed by reviewing each applicant records for accuracy and correctness. HR will conduct employee file audits upon hire and monthly to maintain compliance. See attachment Q&R |
06/09/2023
| Implemented |
| 6400.52(a)(1) | Staff member #1 completed 21 hours of training related to job skills and knowledge for the training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | 55 PA CODE CHAPTER 6400.52(A)(1)-The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.
Biacons Trainer will ensure that all DSP's receive at least 24 hours of training per calendar year. All employees records will be audited every six months for compliance. see attachment S |
02/25/2023
| Implemented |
| 6400.165(g) | Individual#1 takes many psychotropic medications, including abilify, however the only psychotropic medication completed on 12/29/22 does not state which medications are being reviewed, the reason for prescribing the medication, or the need to continue to the medication with the necessary dosage. | 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. | 55 PA Code Chapter 6400.165(g)- 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.
Biacons nurse has implemented the PCHC psychotropic review form and will bring the consumers MAR at each review so all regulatory components are met every 3 months. See Attachment T&U |
03/01/2023
| Implemented |
| 6400.194(d) | The 11/1/22 human rights team minutes for individual#1's restrictive procedure does not include a phase out option for when this procedure can be reduced and/or eliminated. | A record of the human rights team meetings shall be kept. | 55 PA Code Chapter 6400.194(d)- A record of the human rights team meetings shall be kept.
Biacons Administrator will keep a record of the HRC meetings every six months or as needed as changes happen. See attachment V |
03/01/2023
| Implemented |
| 6400.195(a) | Individual#1 has a restrictive component of their behavior support plan that is not included in the ISP, nor does the ISP address the behavior support that has been reviewed or approved by the human rights team. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | 55 PA Code Chapter 6400.195(a)- For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.
Biacons Behavior support specislist will meet with Biacons program specialist monthly and as needed to ensure components of the BSP are reflected in the isp. See attachment W&X |
06/09/2023
| Implemented |