| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(c) | Program Specialist #1, date of hire 04/11/22, does not meet the minimum requirements of the Porgram Specialist position. Program Specialist #1 has 6 verifiable credit hours and 27 months of experience working with persons with intellectual disability. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability. | Allegiant Human Services promoted an employee to the role of Program Specialist that meets the qualifications as defined under 55 PA Code Chapter 6400.44(c). This staff Has been hired to the position of Program Specialist. The staff meets the requirements defined in 6400.44(c)(2). Documentation of their bachelor¿s degree and a resume stating that they have at least 2 years of work experience working directly with individuals with an intellectual disability or autism are on file. [Documentation of education and experience of promoted staff that meets the qualifications for the Program Specialist position was received on 3/21/23 and reviewed 4/7/23. DPOC by HDKP, HSLS, on 4/7/23]. |
02/06/2023
| Implemented |
| 6400.112(e) | A fire drill was conducted in the home during sleeping hours on 06/02/22, and then again on 01/05/23. This exceeds the at least every 6 months requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | Allegiant Human Services will ensure that a fire drill will be held during sleeping hours at least every 6 months. A new Program Specialist was hired to ensure all requirements of fire drills are conducted regularly and accurately. The Program Specialist will ensure that a fire drill will be conducted during sleeping hours at the minimum of once every 6 months. Sleeping hours are defined as between 11:00PM to 7:00AM. Record of the date and time of the fire drill will be documented to ensure that a fire drill is held during sleeping hours. [Additional information received from the agency on 4/17/23: Allegiant Human Services will ensure that a fire drill will be held during sleeping hours at least every 6 months. Fire drills will be conducted during normal staffing conditions with regular staffing patterns. Fire drills will be held unannounced to individuals and staff. A new Program Specialist was hired to ensure all requirements of fire drills are conducted at least monthly and accurately. The Director of Operations will develop a schedule of monthly fire drills to ensure that drills are conducted on different days of the week, at different times of the day and night, not routinely held when additional staff are present, and while all individuals living at the site are present. No notice of the monthly schedule will be provided to the individuals or staff present for the fire drill. The monthly fire drill schedule will be accessible by the Director of Operations only. Staff will be notified of the scheduled fire drill only immediately prior to drill. The Program Specialist will ensure that a fire drill will be conducted during sleeping hours at the minimum of once every 6 months. Sleeping hours are defined as between 11:00PM to 7:00AM. Record of the date and time of the fire drill will be documented to ensure that a fire drill is held during sleeping hours. DPOC by HDKP, HSLS, on 4/18/23]. |
02/14/2023
| Implemented |
| 6400.112(f) | All fire drills conducted in the home between 01/16/22 and 01/05/23 had an evacuation route out the front door only, with alternate exits being available out the back of the home, and the side of the home, verified at the physical site inspection on 02/03/23. | Alternate exit routes shall be used during fire drills. | Allegiant Human Services will vary the location of the fire and the exit routes used to ensure that staff and residents are prepared to respond to different fire scenarios. The Program Specialist will ensure that alternate exit routes will be used during fire drills. Documentation of the fire drill route used to evacuate will be maintained and reviewed to ensure all exit routes are practiced. [Additional information received from the agency on 4/17/23: Allegiant Human Services will vary the location of the fire and the exit routes used to ensure that staff and residents are prepared to respond to different fire scenarios. The Director of Operations will develop a schedule of monthly fire drills and input the schedule into the Exact Payroll program to track fire drills. The monthly fire drill schedule will include the exit route that will be used during the fire drill. The Program Specialist will ensure that alternate exit routes will be used during fire drills. Documentation of the fire drill route used to evacuate will be maintained and reviewed by the Program Specialist quarterly to ensure individuals and staff are prepared to respond to different fire scenarios. DPOC by HDKP, HSLS, on 4/18/23]. |
02/14/2023
| Implemented |
| 6400.113(a) | Individual #1 received fire safety training in the home on 04/16/21, and then again on 07/01/22. This exceeds the annual requirement. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Allegiant Human Services will ensure that each individual shall be instructed in the individual¿s primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home. [Additional information received from the agency on 4/17/23: Allegiant Human Services will ensure that each individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home. Allegiant Human will utilize a program, Exact Payroll, to monitor and document record of training dates of the individuals fire safety training. The Director of Operations will monitor and review the individuals fire safety training record of documentation. The Program Specialist will be responsible that the fire safety training occurs upon admission and annually thereafter. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.141(a) | Individual #1 had a physical examination on 05/21/21, and then again on 07/20/22. This exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual¿s physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the form. [Additional information received from the agency on 4/17/23: Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual's physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the physical examination form. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination conducted on 07/20/22 did not include a review of lifetime medical history. | The physical examination shall include: A review of previous medical history. | Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual¿s physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the form. [Additional information received from the agency on 4/17/23: Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual's physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the physical examination form. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination conducted on 07/20/22 did not address communicable diseases, and the specific precautions that must be taken if the individual has a communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual¿s physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the form. [Additional information received from the agency on 4/17/23: Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual's physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the physical examination form. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination conducted on 07/20/22 did not address the physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual¿s physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the form. [Additional information received from the agency on 4/17/23: Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual's physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the physical examination form. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination conducted on 07/20/22 did not address allergies or contraindicated medications for individual. | The physical examination shall include: Allergies or contraindicated medications. | Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual¿s physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the form. [Additional information received from the agency on 4/17/23: Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual's physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the physical examination form. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination conducted on 07/20/22 did not address medical information pertinent to diagnosis and treatment in the case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual¿s physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the form. [Additional information received from the agency on 4/17/23: Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual's physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the physical examination form. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination conducted on 07/20/22 did not address dietary restrictions for the individual. | The physical examination shall include:Special instructions for the individual's diet. | Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual¿s physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the form. [Additional information received from the agency on 4/17/23: Allegiant Human Services has updated its Individual Physical Examinations Policy to ensure that an individual shall have a physical examination within 12 months prior to admission and then annually thereafter. The Program Specialist will assure that an individual's physical examinations include all requirements as defined under 55 PA Code Chapter 6400.141(c)(1-15). Allegiant Human Services client physical form has been reviewed to confirm that all information is included on the physical examination form. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.181(a) | Individual #1 had an annual assessment completed on 07/01/21, and then again on 01/20/23. This exceeds the annual requirement. [Repeat Violation 02/17/22 et al.] | 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 Program Specialist will complete an initial assessment for each individual within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have assessment completed as required. The Program Specialist will ensure that an individual's assessment is completed and submitted to all the individual's plan team members at least 30 calendar days prior to the individual's plan meeting. The assessment will include all of the assessment components specified at 6400.181(e) may be completed using assessment instruments, interviews, progress notes and observations generated at any time within the previous 365 days except for 6400.181(e)(3), which must include assessments completed within the previous 6 months. [Additional information received from the agency on 4/17/23: The Program Specialist will complete an initial assessment for each individual within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have assessment completed as required. The Program Specialist will ensure that an individual's assessment is completed and submitted to all the individual's plan team members at least 30 calendar days prior to the individual's plan meeting. The assessment will include all of the assessment components specified at 6400.181(e) may be completed using assessment instruments, interviews, progress notes and observations generated at any time within the previous 365 days except for 6400.181(e)(3), which must include assessments completed within the previous 6 months. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed on 01/20/23 did not address recommendations for training, program planning and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist will complete an initial assessment for each individual within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have assessment completed as required. The Program Specialist will ensure that an individual's assessment is completed and submitted to all the individual's plan team members at least 30 calendar days prior to the individual's plan meeting. The assessment will include all of the assessment components specified at 6400.181(e) may be completed using assessment instruments, interviews, progress notes and observations generated at any time within the previous 365 days except for 6400.181(e)(3), which must include assessments completed within the previous 6 months. [Additional information received from the agency on 4/17/23: The Program Specialist will complete an initial assessment for each individual within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have assessment completed as required. The Program Specialist will ensure that an individual's assessment is completed and submitted to all the individual's plan team members at least 30 calendar days prior to the individual's plan meeting. The assessment will include all of the assessment components specified at 6400.181(e) may be completed using assessment instruments, interviews, progress notes and observations generated at any time within the previous 365 days except for 6400.181(e)(3), which must include assessments completed within the previous 6 months. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.46(b) | Direct Service Worker #2 completed fire safety on 04/15/21, and then again on 06/29/22. This exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Allegiant Human Services will ensure that all Program Specialists and direct service workers shall be trained before working with individuals and then annually thereafter by a fire safety expert in the training areas:
¿ General fire safety,
¿ Evacuation procedures,
¿ Responsibilities during fire drills,
¿ The designated meeting place outside the building or within the fire safe area in the event of an actual fire,
¿ Smoking safety procedures if individuals or staff persons smoke at the home,
¿ The use of fire extinguishers, smoke detectors and fire alarms; and
¿ Notification of the local fire department as soon as possible after a fire is discovered.
Allegiant Human Services will ensure that annual fire safety training is provided to staff with no more than 12 months lapse from last training and will be scheduled within 12 months from the last training. [Additional information provided via e-mail by the agency on 4/17/23: The Program Specialists will ensure that all direct service workers shall be trained before working with individuals. The Program Specialist will ensure that annual fire safety training is provided to staff with no more than 12 months lapse from last training and will be scheduled within 12 months from the last training. Allegiant Human Services will utilize a program, Exact Payroll, to maintain compliance with fire safety training for staff. The Director of Operations will utilize the Exact Payroll program to monitor and track fire safety training for all staff. The Director of Operations and the individual staff member will receive notification 60 days prior to the annual due date of the training. Further notification will be provided at 30 days and 14 days if staff member has not completed fire safety training. The Director of Operations will monitor the Exact Payroll program to track training requirements monthly in addition to the due date notifications. DPOC by HDKP, HSLS, on 4/18/23]. |
02/14/2023
| Implemented |
| 6400.181(f) | No documentation was presented at the time of inspection that the assessment for individual #1 completed on 07/01/21, or a current assessment was sent to the SC/ Plan Team prior to the ISP meeting conducted on 02/15/22. [Repeat violation 02/17/22 et al.] | 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 Program Specialist will complete an initial assessment for each individual within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have assessment completed as required. The Program Specialist will ensure that an individual's assessment is completed and submitted to all the individual's plan team members at least 30 calendar days prior to the individual's plan meeting. The assessment will include all of the assessment components specified at 6400.181(e) may be completed using assessment instruments, interviews, progress notes and observations generated at any time within the previous 365 days except for 6400.181(e)(3), which must include assessments completed within the previous 6 months. [Additional information received from the agency on 4/17/23: The Program Specialist will complete an initial assessment for each individual within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have assessment completed as required. The Program Specialist will ensure that an individual's assessment is completed and submitted to all the individual's plan team members at least 30 calendar days prior to the individual's plan meeting. The assessment will include all of the assessment components specified at 6400.181(e) may be completed using assessment instruments, interviews, progress notes and observations generated at any time within the previous 365 days except for 6400.181(e)(3), which must include assessments completed within the previous 6 months. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |