| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | A fire drill was conducted during sleeping hours in the home on 06/03/22, and then again on 01/08/23. 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 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 |
| 6400.141(a) | Individual #1 had a physical examination conducted on 08/19/21, and then again on 09/18/22. This exceeds the annual requirement. Individual #2 had a physical examination on 12/08/20, and no other physical examination documentation was provided to measure compliance with this regulation. | 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)(4) | Individual #1 had a hearing screening conducted on 08/19/21, and then again on 10/28/22. This exceeds the annual requirement. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 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 09/18/22 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 09/18/22 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 09/18/22 did not address allergies or contraindicated medications for individual #1. | 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 09/18/22 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 09/18/22 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 07/30/21, and then again on 11/01/22. 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 |
| 6400.165(g) | Individual #2 had a review of medications prescribed for treatment of a psychiatric illness on 02/15/22, and then again on 07/21/22. This exceeds the every 3-month requirement. Individual #2 had a review of medications prescribed for treatment of a psychiatric illness on 08/18/22, and then again on 01/12/23. This exceeds the every 3-month requirement. Individual #2's medication reviews conducted on 0721/22, 08/18/22, and 01/12/23 did not include the name of the medication, the dosage of the medication, or the reason for prescribing. | 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. | Allegiant Human Services has hired a new Program Specialist to handle all responsibilities as defined for the position including maintaining documentation of reviews of medication prescribed to treat symptoms of psychiatric illness. The Program Specialist has reviewed the regulations of prescription medications as specified under 6400.165(a-g). The Program Specialist will provide documentation of the psychiatric medication review form to the prescribing physician to be completed at least every 3 months. The psychiatric medication review form includes the prescribed medication, dosage, reason for prescription, the need to continue medication, and the necessary dosage. [Additional information received from the agency on 4/17/23: Allegiant Human Services has hired a new Program Specialist to handle all responsibilities as defined for the position including maintaining documentation of reviews of medication prescribed to treat symptoms of psychiatric illness. The Program Specialist has reviewed the regulations of prescription medications as specified under 6400.165(a-g). Acknowledgment of the policy training and review has been documented. Allegiant Human Services requires and provides Chapter 6400 Regulations review and training annually. The Program Specialist will provide documentation of the psychiatric medication review form to the prescribing physician to be completed at least every 3 months. The psychiatric medication review form includes the prescribed medication, dosage, reason for prescription, the need to continue medication, and the necessary dosage. DPOC by HDKP, HSLS, on 4/18/23]. |
03/17/2023
| Implemented |
| 6400.181(f) | No documentation was presented at the time of inspection that the assessment for individual #1 completed on 11/01/22 was sent to the SC/ Plan Team at least 30 days prior to the ISP meeting conducted on 12/21/22. No documentation was presented at the time of inspection that the assessment for individual #2's completed on 09/01/22 was sent to the SC/ Plan Team at least 30 days prior to the ISP meeting conducted on 10/07/22. [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 |