| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is not a source of light outside the sunporch exit leading to the back of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The front and back exits of the house had proper lighting, however the side porch exit of the home did not have a light source. On November 21st, 2022 a new flood light structure was put up along the house approximately 10ft away and 10ft up in the air from the exit. It is a sensor light and goes off whenever there is any motion. This ensures the safety of all clients and staff in the even they have any need to exit the side porch. |
11/21/2022
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed on 2/3/2022, does not include the individual's needs. Individual #2's assessment, completed on 8/5/2022, does not include the individual's needs. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #1 & #2's assessments in 2022 only included the clients functional strengths & preferences. The clients individual need's is also required. On November 30th, CEO & Program Specialist had a meeting in reference to this violation. Program specialist revised and included Individual's needs in the Annual Assessment. |
11/30/2022
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's assessment, completed 2/3/2022, does not include individual's current level of performance and progress in acquisition of functional skills. Individual #2's assessment, completed 8/5/2022, does not include individual's current level of performance and progress in acquisition of functional skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | Individual #1 & #2's assessments in 2022 was lacking sufficient information of clients acquisition of functional skills. On November 30th, CEO & Program Specialist had a meeting in reference to this violation. Program specialist revised and gave a detailed, specific report of clients current assessment of acquisition of functional skills. |
11/30/2022
| Implemented |
| 6400.181(e)(4) | Individual #2's assessment, completed 8/5/2022, does not include the individual's need for supervision. | The assessment must include the following information: The individual's need for supervision.
| Individual #2's annual assessments in 2022 was lacking sufficient information of clients need for supervision. Client is very self-sufficient, however that documentation needs to be in place in order for all parties to understand. On November 30th, CEO & Program Specialist had a meeting in reference to this violation. Program specialist revised and gave a detailed, specific report of clients need for supervision. |
11/30/2022
| Implemented |
| 6400.181(e)(7) | Individual #2's assessment, completed 8/5/2022, does not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Individual #2's annual assessments in 2022 included his ability to temper water for bathing, however it lacked is ability to know the dangers of heat sources such as a stove or oven. Client is very self-sufficient, however that documentation needs to be in place in order for all parties to understand. On November 30th, CEO & Program Specialist met with client and verified that he does indeed know the dangers of heat sources above 120degrees. We reviewed proper handling of stove top and oven pans. Client demonstrated that he holds his hands close, without touch to ensure that he will not get burned. Program specialist revised and gave a detailed, specific report of clients need for supervision. |
11/30/2022
| Implemented |
| 6400.181(e)(8) | Individual #2's assessment, completed 8/5/2022, does not include the individual's ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Individual #2's assessment did not include a detailed explanation of the client ability to evacuate during a fire. On November 30th, CEO & Program Specialist met with client and reviewed his ability and competence to evacuate during a fire. We then completed an unannounced fire drill an hour later. Client successfully evacuated in time, correctly, and far enough from the house in a safe location. |
11/30/2022
| Implemented |
| 6400.181(e)(9) | Individual #2's assessment, completed 8/5/2022, does not include documentation of the individual's disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual #2's assessment did not provide actual diagnosis & disabilities. On November 30th, CEO & Programs Specialist reviewed clients ISP, along with Psych Med Eval & Reviews. This information was documented successfully in the annual assessment. |
11/30/2022
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 2/3/2022, does not include a lifetime medical history. Individual #2's assessment, completed 8/5/2022, does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Both clients 1 & 2 annual assessments did not include their lifetime medical history. This information is on file and also in clients ISP. On November 30th, CEO & Program Specialist both reviewed this information. PS inputted the lifetime medical history correctly for both clients. |
11/30/2022
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment, completed 2/3/2022, does not include the individual's psychological evaluation. Individual #2's assessment, completed 8/5/2022, does not include the individual's psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | Individual #1 did have a psychological evaluation, however it was not included in their annual assessment. On November 30th, CEO & Program Specialist reviewed and included this information in his assessment. Individual #2 did not have a psych eval on hand or in his ISP. CEO has reached out to SC to see if one exist on file for him. If client does not have one, that will be documented as such. |
11/30/2022
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 2/3/2022, does not include recommendations for specific areas of training, programming and servces. Individual #2's assessment, completed 8/5/2022, does not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual's #1 & #2 assessment did not included detailed recommendations of specific areas of training, programming & services. On November 30th CEO & Program Specialist properly documented the recommendations that we believe will improve the clients everyday life. |
11/30/2022
| Implemented |
| 6400.15(b) | The agency completed a self-assessment of the home on 06/2/2022; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Staff used the 2018 Self-Assessment form, rather than the most recent department edition from 2020 located in the RGC manual. On November 29th, CEO & staff completed the correct/current edition of the Self-Assessment form from the back of the RGC manual. |
11/29/2022
| Implemented |
| 6400.51(b)(1) | Direct Service Worker #1, date of hire 2/27/2022, completed training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 4/3/2022. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | DSW #1 was hired as part time on 2/27/2022, but only worked 3 days from 2-27-2022 to 4-3-2022 with other staff present. Client finished last training of Person Centered Practices on 4/3/2022. This is outside of the 30 day range. On November 29th, CEO put into training manual if a staff is part time or not, no matter how many days they work in a 30 day span , they must complete all orientation training within 30 days. If staff only work a couple days and cannot complete on their shifts, they must do them on their own time. |
11/29/2022
| Implemented |
| 6400.51(b)(2) | Direct Service Worker #2, date of hire 1/2/2022, completed training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act on 5/11/2022. Direct Service Worker #1, date of hire 2/27/2022, completed training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act on 11/9/2022. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | The proper orientation training covering the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act was not done within 30 days of hire for DSW#2. Similar trainings, but not the ODP department trainings were done. On November 30th, CEO & Program Specialist created a staff training syllabus that all new hires follow. We also created an annual training catalog. This to ensure proper training is done. |
11/30/2022
| Implemented |
| 6400.52(c)(1) | Program Specialist #3's annual training hours for the training year, from 1/1/2021 through 12/31/2021, did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | On November 29th, CEO reviewed with Program Specialist the required trainings of the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. We created a syllabus to follows this training. This was already done in 2022, however we reviewed to ensure this is not missed again. |
11/29/2022
| Implemented |
| 6400.52(c)(2) | Program Specialist #3's annual training hours for the training year, from 1/1/2021 through 12/31/2021, did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. [Repeat Violation, 11/19/2021] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | On November 29th, CEO reviewed with Program Specialist the required trainings of the application of the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act . We created a syllabus to follows this training. This was already done in 2022, however we reviewed to ensure this is not missed again. |
11/29/2022
| Implemented |
| 6400.52(c)(3) | Program Specialist #3's annual training hours for the training year, from 1/1/2021 through 12/31/2021, did not include individual rights. [Repeat Violation, 11/19/2021] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | On November 29th, CEO reviewed with Program Specialist the required trainings of the clients individual rights. We created a syllabus to follows this training. The proper ODP trainings were already done in 2022, however we reviewed to ensure this is not missed again. |
11/29/2022
| Implemented |
| 6400.52(c)(4) | Program Specialist #3's annual training hours for the training year, from 1/1/2021 through 12/31/2021, did not include recognizing and reporting incidents. [Repeat Violation, 11/19/2021] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | On November 29th, CEO reviewed with Program Specialist the required trainings of recognizing and reporting incidents. We created a syllabus to follows this training. This was already done in 2022, however we reviewed to ensure this is not missed again. |
11/29/2022
| Implemented |
| 6400.52(c)(6) | Program Specialist #3's annual training hours for the training year, from 1/1/2021 through 12/31/2021 did not include implementation of the individual plan. [Repeat Violation, 11/19/2021] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | On November 29th, CEO reviewed with Program Specialist the required trainings of reviewing client ISP's prior to moving into home. We created a syllabus to follows this training. This was already done in 2022, however we reviewed to ensure this is not missed again. |
11/29/2022
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment, completed 2/3/2022, to the individual plan team members for the individual plan meeting on 6/22/2022. The program specialist did not provide Individual #2's assessment, completed 8/5/2022, to the individual plan team members for a individual plan meeting on 10/6/2022. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Specialist provided individual #1's & #2's annual assessments to their Individual plan team at the team meeting, 30 days later than required. Client #2's individual team meeting is over 90 days away, but updated assessment will be provided at least 30 days prior. Individual #2's next team meeting is December 7th. It was sent out to his team on December 1st. This is under 30 days, however state inspection POC was just done 12 days ago. |
12/01/2022
| Implemented |