| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The plastic handrail that surrounded the front porch was able to moved approximately an inch and a half in both directions when grasped to check stability. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The Agency decided to install a new, well secured handrail. Penn Fencing was contacted and has scheduled for the installation on August 20. |
08/20/2021
| Implemented |
| 6400.80(a) | The wooden ramp leading from the driveway to the front of the home, which is comprised of 19 boards lined up horizontally encompassed the numerous tripping and falling hazards. The 7th board from the driveway is bowed and recessed one inch in the middle and protruding one inch on the end from the 6th and 8th board. The 9th board is bowed and recessed one inch below the 8th and 10th board. The 11th board is also bowed and recessed three quarters from the 10th and 12th board. In addition, the wooden hand railing along this ramp had multiple nail heads protruding about a quarter of an inch from the top posing a puncture and laceration risk. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The three bowed boards were replaced with new ones on August 8. Also on same date, the protruding nails were fixed and smoothened in such a way that they no longer pose any hazard |
08/08/2021
| Implemented |
| 6400.101 | The sidewalk leading to the outside steps and front porch of the home was obstructed by vegetation approximately 2 feet high and 6 inches wide. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The vegetation was cleared out on August 9. |
08/09/2021
| Implemented |
| 6400.112(c) | The written fire drill record for a fire drill held on 7/7/21 documented Individual #1 as participating in the fire drill. Individual #1 left the home on 7/1/21 and has not returned to the home as 7/27/21. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Program Specialist made a mistake with dates on the July fire drill record that was sent as part of the pre-inspection documents to the Licensing Representative. This mistake was discovered and corrected before the inspection day as evidenced in the fact that the fire drill folder that was submitted to the licensing representatives during the on-site inspection did not contain the mistake. |
07/23/2021
| Implemented |
| 6400.181(d) | The assessment completed for Individual #1 was not signed or dated by Program Specialist #1 | The program specialist shall sign and date the assessment. | Once it was brought to his notice on the inspection day, the Program Specialist signed and dated the assessment |
07/27/2021
| Implemented |
| 6400.181(e)(14) | The assessment completed for Individual #1 did not include the individual's knowledge of water safety and ability to swim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Once brought to his notice on the inspection day, the Program Specialist added the missing information on the individual's knowledge of water safety and ability to swim |
07/27/2021
| Implemented |
| 6400.18(a)(8) | On 5/11/21, Individual #1 called 911 from his cellular phone. A local Police Department Officer, arrived at the home and then after speaking with Individual #1, contacted the ambulance services and explained to them to not come to the home. The agency entered an incident of an Emergency Room Visit for Individual #1 in the Department Information Management system. An incident of law enforcement activity was not reported. Individual #1 did not go to the Emergency Department. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| This is a mistake with categorization. The law enforcement activity was accurately reported on the incident description. The Agency contacted the AE on August 9 to help recategorize the incident. The AE accepted to recategorize the incident. |
08/09/2021
| Implemented |
| 6400.186 | Individual #1's support plan, effective date 7/1/2020 indicates the individual requires 24 hour supervision. Individual #1, date of admission 4/19/21, has been absent from the home from 5/19/21 to 6/6/21 and 7/1/21 to 7/27/21. | The home shall implement the individual plan, including revisions. | The individual decided to move out from the program, to go stay with his friend. The Agency cannot stop the individual as that would violate the individual rights. This has been a pattern for years, and has defied any plan by the care team to help keep him on track. Once the individual left, the Agency informed the care team including the County Representative, Support Coordinator, Mercy Behavioral, and the individual's sister. During the conversation with the County Representative, she confirmed that there is nothing we can do as an Agency. |
07/01/2021
| Implemented |