| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Services Worker #2, date of hire 1/18/2021, had a request for a Pennsylvania criminal background check submitted 2/19/2021. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The 1/19/21 hire date for DSW 2 was a clerical error. Paychex records reflect that the hire date of the staff is 2/22/21. The criminal background check was completed on 2/19/21, 3 days prior to the hire date. The staff file has been corrected to reflect the correct hire date of 2/22/21. |
03/29/2021
| Implemented |
| 6400.141(c)(4) | Individual #2, date of admission 9/25/2020, had a physical examination, dated 2/24/2021; however, the physical examination did not include a hearing or vision screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual # 2 had a vision appointment completed on December 14, 2020. Please see the documentation for that appointment.
There is a hearing exam appointment scheduled for April 22, 2021 at 2:30 pm, with Hearing Unlimited. Documentation of this appointment will be completed and placed in the individuals file. |
04/01/2021
| Implemented |
| 6400.141(c)(7) | Individual #2, date of admission 9/25/2020, does not have record of a gynecological examination. Individual #2 is over 18 years of age. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The individual was seen by a gynecologist on March 31,2021. During that appointment the individual refused to receive a gyne exam. The doctor gave the agency in exempt notice and the refusal was documented. The individual is exempted until the age of 21. |
04/01/2021
| Implemented |
| 6400.142(a) | Individual #2, date of admission 9/25/2020, does not have record of dental examinations. Individual #2 is over 18 years of age. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | the individual has a dental appointment scheduled for May 11 2021. |
04/01/2021
| Implemented |
| 6400.143(a) | Individual #2, date of admission 9/25/2020, refused to attend a psychiatric appointment on 1/11/2021; however, the agency failed to document the continued attempts to train the individual about the need for healthcare. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The individual¿s psychiatric appointment is scheduled for April 20th 2021 |
04/01/2021
| Implemented |
| 6400.151(a) | Direct Services Worker #2, date of hire 1/18/2021, had a physical examination completed 1/19/2021. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The 1/18/21 hire date for DSW 2 was a clerical error. Paychex records reflect that the hire date of the staff is 2/22/21. The criminal background check was completed on 2/19/21, 3 days prior to the hire date. The staff file has been corrected to reflect the correct hire date of 2/22/21. |
04/01/2021
| Implemented |
| 6400.181(a) | Individual #2, date of admission 9/25/2020, had an initial assessment completed on 12/17/2020, 83 days after admission. | 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. | The agency was under the impression that the individual was still a respite on September 25, 2020, as the financial waiver did not convert to a consolidated until October 17, 2020 agency is now informed that after 30 days of respite individuals are to be switched over to residential status. The financial portion does not determine or effect the services received and the no more that 30 days of respite is allowed, despite still being paid as respite. All individuals will be converted to residential participants after 30 days of respite. An admissions checklist was created to include all the 6400 regulatory requirements, including residential assessment. The administrative liaison and program were trained in the use and implementation of this document. |
04/01/2021
| Implemented |
| 6400.34(a) | Individual #2, date of admission 9/25/2020, did not receive the information and explanation of individual rights upon admission. This information was provided on 10/17/2020. | 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. | The agency was under the impression that the individual was still a respite on September 25, 2020, as the financial waiver did not convert to a consolidated until October 17, 2020 agency is now informed that after 30 days of respite individuals are to be switched over to residential status. The financial portion does not determine or effect the services received and the no more that 30 days of respite is allowed, despite still being paid as respite. All individuals will be converted to residential participants after 30 days of respite. The administrative liaison was trained in the use of this document. |
04/01/2021
| Implemented |
| 6400.46(b) | Program Specialist #1's, date of hire 7/15/2018, most recent fire safety training by a fire safety expert occurred on 11/12/2019. Direct Services Worker #3, date of hire 8/27/2019, completed fire safety training by a fire safety expert on 5/6/2019, and then again on 9/02/2020. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The program specialist completed fire safety on March 12, 2021. |
04/01/2021
| Implemented |
| 6400.181(f) | Program Specialist #1, date of hire 7/15/2018, provided Individual #1's assessment, dated 8/25/2020, to the plan team members on 3/11/2021 for the ISP meeting that occurred on 1/28/2021. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The agency has developed an assessment policy, which includes that the assessment must be completed and sent to the plan team at least 30 days prior to the ISP meeting. An assessment checklist has been created, which includes "sending the assessment to the plan team as soon as it is completed, signed, and dated, and sending it upon receipt of the ISP invitation. Program specialist has been trained on the use and implementation of this form and policy. |
04/01/2021
| Implemented |