| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(b) | Staff # 1's date of hire was 03/01/2017, was not a PA resident for two years and a FBI clearance was not completed. | If a prospective employe who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. | Center Director registered staff #1 with Cogent to complete her FBI clearance at the designated location. The center is awaiting for the clearance to be received at the staff members home. See Cogent payment receipt attachment #8.(the executive director or designee will conduct staff record audits to ensure all staff have a completed FBI clearance if applicable DS 05.11.17) |
03/28/2017
| Implemented |
| 2380.36(b) | The CEO had zero training hours for the 01/01/2016-12/31/2016 training year. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | Moving forward the Regional Director of PA - Dawn Menya will be listed as the CEO for the Senior Care Centers of America and therefor her file will be maintained at the center and her training record will be maintained in the center. (the executive director or designee will develop a tracking system to ensure staff receive 24 hours of training annually. DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.53(a) | Provon Perineal Skin Protectant ointment which indicated to contact poison control if ingested was found unlocked in a storage bin in the bathroom located near the back door. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Center Director has disposed of the ointment that indicated, contact poison control if ingested. Center Director will conduct weekly checks to ensure that center remains in compliance.(the executive director or designee will retrain all staff on the proper store of poisonous substances DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.53(b) | There was a clear bottle labeled Bruclean and Renown Floor Cleaner found in the storage closet | Poisonous materials shall be stored in their original, labeled containers. | Center Director has disposed of the clear bottles that were not in their original containers - labeled Bruclean and Renown Floor Cleaner. The Center Director will do weekly checks to ensure cleaning supplies are in the correct bottles and remained locked in the corrected locked area of the center. (the executive director or designee will retrain all staff on the importance of poisonous substances remaining in the original containers. DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.67(a) | There was peeling fabric approximately six inches in diameter on the headrest of the chair located in the activity area. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Two new recliners have been ordered to replace the chairs that have the peeling fabric, we are awaiting their delivery. See the attached proposal for Workplace Interiors attachment #7. (the executive director or designee will conduct weekly physical site inspections to ensure continued compliance with this regulation. DS 05.11.17) |
05/01/2017
| Implemented |
| 2380.89(g) | The fire drill records from February 2016 through February 2017 did not document the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | An updated fire dire that includes the designated meeting place has been implemented. The designated meeting place for this center is the rear of the parking lot and all members have been made aware of the designated meeting place. Please see the updated Fire Drill and Disaster Drill Report Attachment #6
(the executive director or designee will conduct monthly audits of fire drill records to ensure the records are completed in accordance with the regulations. DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.111(c)(1) | Individual # 1's physical examination dated 03/15/2016 did not document a medical history review. | The physical examination shall include: A review of previous medical history. | All physical examinations will include a review of the previous medial history. Annual Physical Examination Form Attachment #5. (The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to have blank spaces on the physical examination related to regulations, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.111(c)(7) | Individual # 2's physical examination dated 02/13/17 did not document health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | All physical examinations will include an assessment of the individuals health maintenance needs, medication regimen and the need for blood work at recommended intervals. Annual Physical Examination Form Attachment #5(The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to have blank spaces on the physical examination related to regulations, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.111(c)(8) | Individual # 2's physical examination dated 02/13/2017 did not document physical limitations. | The physical examination shall include: Physical limitations of the individual. | All physical examinations will include the physical limitations of the individual. See the annual physical examination attachment #5(The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to have blank spaces on the physical examination related to regulations, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.111(c)(9) | Individual # 2's physical examination dated 02/13/2017 did not document allergies. | The physical examination shall include: Allergies or contraindicated medication. | All physical examinations will include allergies or contraindicated medications. See Annual Physical Examination attachment #5.(The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to have blank spaces on the physical examination related to regulations, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.111(c)(10) | Individual # 1's physical examination dated 03/15/2016 did not document information pertinent to diagnosis and treatment in case of an emergency.
Individual # 2's physical examination dated 02/13/2017 did not document information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | All physical examinations shall include medical information pertinent to diagnosis and treatment in case of an emergency. See Annual Physical Examination attachment #5(The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to have blank spaces on the physical examination related to regulations, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.111(c)(11) | Individual # 2's physical examination dated 02/13/2017 did not document diet instructions. | The physical examination shall include: Special instructions for an individual's diet. | All physical examinations will include special instructions for an individuals diet. See Annual Physical Examination attachment #5.(The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to have blank spaces on the physical examination related to regulations, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.173(1)(ii) | Individual # 1 and Individual # 2's record did not document identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | All member Nursing Assessment records will include the following information that will be completed in its entirety : personal information, including race, height, weight, eye color, hair color and identify marks. If there are no identifying marks the Nursing Assessments will be stated as such. See attachment #4(The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to be missing personal information, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.181(c) | Individual # 1's assessment dated 08/15/2016 did not document the basis of the assessment.
Individual # 2's annual assessment dated 07/21/2016 did not document the basis of the assessment. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | All assessments will document the basis of the assessment and include statement " Agency representative based this assessment on the participant's ISP, interview with participant, interview(s) 3with staff, monthly progress notes, and/or observation." see attachment # (All program specialists will be retrained in their duties. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to out of compliance, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.181(e)(12) | Individual # 1's assessment dated 08/15/2016 did not document recommendations for training, programming and services.
Individual # 2's annual assessment dated 07/21/2016 did not document recommendations for training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | All assessments will include the statement " Progress and growth in the area of the community integration and Recommendation for training, vocational programs, and competitive and community integrated employment." See attachment #3.All program specialists will be retrained in their duties. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to out of compliance, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.181(e)(13)(i) | Individual # 2's annual assessment dated 07/21/2016 did not document progress and growth in the area of health | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health. | All assessments will include the statement "progress and growth in the area of health" See attachment #3 (All program specialists will be retrained in their duties. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to out of compliance, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.181(e)(13)(ii) | Individual # 2's annual assessment dated 07/21/2016 did not document progress and growth in the area of motor and communication. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | All assessments will include the statement "Progress and growth in the areas of motor and communication skills" see attachment #3 (All program specialists will be retrained in their duties. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to out of compliance, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual # 2's annual assessment dated 07/21/2016 did not document progress and growth in the area of socialization. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | All assessments will now include a section that states "Progress and grown in the areas of Socialization and Personal Adjustment. See attachment #3 (All program specialists will be retrained in their duties. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to out of compliance, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.181(e)(13)(v) | Individual # 2's annual assessment dated 07/21/2016 did not document progress and growth in the area of recreation | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | The assessment will document recreation interests as well as progress and growth in the area of recreation - Community Involvement: Community groups/involvement scheduled throughout each month. See attachment #3
(All program specialists will be retrained in their duties. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to out of compliance, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.181(e)(13)(vi) | Individual # 2's annual assessment dated 07/21/2016 did not document progress and growth in the area of community integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | The assessment will document recreation interests as well as progress and growth in the area of recreation - Community Involvement: Community groups/involvement scheduled throughout each month. See attachment #3
(All program specialists will be retrained in their duties. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to out of compliance, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 05.11.17) |
03/31/2107
| Implemented |
| 2380.181(f) | There was no documentation Individual # 1's assessment dated 08/15/2016 was sent to team members prior to the ISP meeting held on 09/14/2016. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | All assessments will be emailed to the SC or plan lead as applicable and plan team members at least 30 calendar days prior to the ISP meeting for the development and annual update. (The program specialist will be retrained in their job duties. The program specialist will develop a tracking tool to ensure the assessments are sent to team members at least 30 days prior to the ISP meeting. The executive director or designee will conduct quarterly audits to ensure continued compliance with this regulation DS 05.11.17) |
03/31/2017
| Implemented |
| 2380.185(b) | There were no strategies developed to track progress towards Individual # 2's outcome of "daily activity". | The ISP shall be implemented as written. | Strategies to track progress for each individual member were developed and documented as center specific goal in monthly progress notes, quarterly reviews and initial/annual assessments. Please attached monthly progress note (attachment #1), quarterly review (attachment #2) and initial/annual assessment (attachment #3) |
03/31/2017
| Implemented |