| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Greater than 5 days elapsed between the hire and criminal background check dates for the following staff: Staff Members 1, 2, 3, 4, 5, 6, and 7. The following staff have criminal checks on file that were greater than one year old at the time of their hire: Staff Members 8 and 9. Staff Members 10, 11, 12, 13, 14, 15, and 16 were all hired in 2023 and do not have completed criminal background checks on file with the agency. | 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.
| Human Resource Manager reviewed file to assure new hire packet background check were completed within timeframe of hire date. Staff members 10-13 and 15-16 background checks were submitted with correction plan. Staff member 14 did was a previous employee who separated from the company on February 2023 and returned in July of 2023. Therefore, a new background check was not necessary. |
01/01/2024
| Implemented |
| 6400.81(k)(6) | There was no mirror in individual 1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Maintenance Team placed a mirror in individual 1 bedroom. |
01/16/2024
| Implemented |
| 6400.104 | The agency's fire department notices do not list the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The fire department notices will be resent to include layout of home identifying location of individual bedroom. |
01/31/2024
| Implemented |
| 6400.151(a) | Staff Member 6 does not have a physical on file. | 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. | Upon a review of the file by the HR Manager staff member 6 physical was located and submitted during correction plan. Additionally, Employee 6 took the physical form to doctor office to be completed. |
01/24/2024
| Implemented |
| 6400.151(c)(3) | Staff Member 15's 3/6/23 physical does not contain a signed statement from the doctor clearing them of communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff member 15 took physical form to be fully completed by physician and returned. A policy was developed stating all new hires must have Independence Support Services physical form completed that is in compliance with regulations. A policy was developed stating all new hires must have Independence Support Services physical form completed that is in compliance with regulations. |
01/31/2024
| Implemented |
| 6400.151(c)(4) | Staff Member 15's 3/6/23 physical does not contain consideration of medical problems which might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Staff member 15 took physical form to be fully completed by physician and returned. A policy was developed stating all new hires must have Independence Support Services physical form completed that is in compliance with regulations. |
01/31/2024
| Implemented |
| 6400.181(c) | Individual 1's 10/1/23 assessment does not list the sources of its information. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Program Specialist revised form to include how assessment was completed |
01/01/2024
| Implemented |
| 6400.181(e)(12) | Individual 1's 10/1/23 assessment does not contain recommendations for training, programs, or services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist revised assessment to include recommendations for specific areas of training, programming and services. |
01/01/2024
| Implemented |
| 6400.165(c) | Cannot determine if medication (Clonidine .1 tab) was dispensed to Individual 1. There is no blister pack to indicate corresponding date of medication for AM dosage. There was only a blister pack for 4 pm dosage that was unused. | A prescription medication shall be administered as prescribed. | Incident report was entered to reflect the medication error. House manager reviewed all medication to assure it aligned to MAR and administered accordingly. Director of Health services reviewed medication administration procedures with staff identifying breakdown and action steps to prevent a reoccurrence. This included reviewing all medication being accounted for prior to administration |
01/31/2024
| Implemented |
| 6400.213(1)(i) | Individual 1's file does not contain a record of identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Director fo Health Services amended face sheet for individual 1to include all identifying marks. |
01/24/2024
| Implemented |