| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(d) | Staff #1's date of hire was 7/17/17 and he/she did not have training on disabilities at the time of licensing on 10/30/17. | Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | All new staff new staff are trained in are to be trained in Every Lives and working with individuals with disabilities. At the time of the inspection staff #1 did not have training. 10/30/2017, on disabilities. Staff #1 had training on disabilities on 12/1/2017. New Hire Orientation has been updated to include training on servicing individuals with disabilities with trainings on Everyday Lives and Community Participation Supports. The Program Specialist and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.36(f) | Staff #2 had fire safety training on 5/20/16 and not again until 5/30/17. | Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f). | All staff annual fire safety training will be schedule prior to the previous year¿s completed date in order to remain in compliance |
12/12/2017
| Implemented |
| 2380.53(a) | Antiseptic spray that contained a label to contact poison control center was found unlocked and accessible in the first aid kit in the nurse's office that was unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Effective immediately, the nursing office will remained locked when not in use and the first aid kit will be maintained in a locked cabinet when not in use |
12/12/2017
| Implemented |
| 2380.55(d) | During the physical site inspection of the facility, trash in the male and female bathrooms and trash in the kitchen was found in receptacles that were not covered. | Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents. | It is important that the trash receptacles remain covered in the bathroom and kitchen areas in order to prevent the penetration of insects and rodents. At the time of the inspection 10/30/2017 the trash receptacles in the male and female bathrooms as well as the kitchen were not covered. The trash receptacles all have lids ¿ all staff have been instructed to keep the lids on all receptacles at all times 12/01/2017. The Center Director will ensure that during the weekly walk through if a trash can is missing a lid it is immediately replaced to ensure that the center remains free of insects and rodents. |
12/01/2017
| Implemented |
| 2380.58(a) | There was approximately a 3 foot scrape in the female's bathroom that scraped the drywall and paint off of the wall. Above the scrape was approximately a tennis sized hole in the wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | ¿ it is important for all surfaces to be in good repair to ensure the health and safety of all members. At the time of the inspection the walls in the ladies room were not in good repair. On 11/4/2017 the walls in the ladies restroom were repaired by the handyman. The Center Director will do a walkthrough of the center on a weekly basis to ensure all surfaces are in good repair and report all issues to the facilities handyman so that they can immediately addressed. |
03/27/2018
| Implemented |
| 2380.70(b) | The first aid area was not equipped with a bed or cot or pillow. The first aid area had a geriatric chair that reclined but did not contain a bed or cot. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | It is important to have a place for members to rest when they are unwell or need a quiet place to relax and be away from the rest of the members. In order to have a place for this to occur every licensed center will be equipped with a bed/cot, pillow and a blanket within the first aid area. At the time of the inspection the center did not have these items. On 12/14/2017 the Center Director purchased a folded cot and pillow for the first aid area. |
03/27/2018
| Implemented |
| 2380.83(a) | The emergency evacuation plan did not include the emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. | The emergency evacuation plan has been updated to include the Clifton Heights Borough Shelter. (Attachment #7) |
12/15/2017
| Implemented |
| 2380.111(c)(8) | Individual #1 2/6/17 physical exam did not indicate his/her physical limitations such as his/her daily use of a walker due to unsteady gait. The physical form indicated limitations or restrictions for activities: no.' | The physical examination shall include: Physical limitations of the individual. | The Program team will review the physical and the ISP document to ensure accuracy of both documents upon receipt. If documents are found to have discrepancies they will document their findings and follow up with the appropriate parties to obtain accurate information |
12/15/2017
| Implemented |
| 2380.111(c)(9) | Individual #1's 2/6/17 physical exam did not indicate that he/she was allergic to cat fur, as his/her assessment and Individual Support Plan (ISP) indicate. Individual #2's physical dated 1/8/17 did not state allergies. | The physical examination shall include: Allergies or contraindicated medication. | It is important to have a current physical for all person supported within the program in order to ensure their health and safety. Individual #1 physical did not state that she was allergic to cat fur as stated in her ISP and her assessment. Individual #1 physical was updated 2/21/2018 that states she has allergy to cat fur. The Program team will review the physical and the ISP document to ensure accuracy of both documents upon receipt. If documents are found to have discrepancies they will document their findings and follow up with the appropriate parties to obtain accurate information. The RN and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.111(c)(10) | Individual #1's 2/6/17 physical exam form did not include information pertinent to diagnosis and treatment in case of an emergency. He/She used a walker daily, has some incontinence and he/she garbled' for communication which would require a familiar staff to relay emergency or medical information, and wears hearing aids due to hearing loss. This information was not included on the physical form. Individual #2's physical dated 1/8/17 did not include information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | It is important to have a current physical for all person supported within the program in order to ensure their health and safety. Individual #1 physical did not include information pertinent to diagnosis and treatment in case of an emergency. Individual #1 physical was updated 2/21/2018 that states that she ambulates using a walker. The Program team will review the physical and the ISP document to ensure accuracy of both documents upon receipt. If documents are found to have discrepancies they will document their findings and follow up with the appropriate parties to obtain accurate information. The RN and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.111(c)(11) | Individual #1 2/6/17 physical exam form did not include his/her diet. The form indicated continue current diet' but did not indicate what that diet consisted of. | The physical examination shall include: Special instructions for an individual's diet. | ¿ It is important to have a current physical for all person supported within the program in order to ensure their health and safety. Individual #1 physical did not include information regarding special instructions for her diet Individual #1 physical was updated 2/21/2018 that states that she is on a regular house diet. The Program team will review the physical and the ISP document to ensure accuracy of both documents upon receipt. If documents are found to have discrepancies they will document their findings and follow up with the appropriate parties to obtain accurate information. The RN and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.115(1) | The emergency medical plan did not include the hospital or source of health care for individuals in the event of an emergency. | The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | The emergency medical plan has been updated to include the Mercy Fitzgerald and Delaware County Memorial Hospital ¿ depending on which 911 services is contacted. (Attachment #6) |
12/15/2017
| Implemented |
| 2380.124(b) | Individual #3 7/25/17 and 10/19/17 medication administration record (mar) was not initialed after the 2pm dose of acetaminophen 325mg as needed. The agency indicated to licensing that the medication was administered however the staff did not initial the MAR immediately after administration. | The information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication. | During the dates in question an agency nurse was on site, as of 11/13/2017 the center has a fulltime Registered Nurse on site. The RN will ensure all medications that are administered are signed for at the time of administration. It is important to ensure all members receive their prescribed medications while attending the ATF. The RN will review the MAR daily to ensure all administered and documented as prescribed. In the absences of the facility RN the Center Director, who is also an RN, will review the medication logs to ensure that all medications were given and documented. The RN and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.173(1)(ii) | Individual #1 and #2's record did not include his/her 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. | Demographic sheet will be updated for all members to include race, height, weight, color of hair, color of eyes and identifying marks. (Attachment #5 |
12/15/2017
| Implemented |
| 2380.173(9) | Individual #1 9/1/17 assessment indicated he/she was to follow a regular diet. However he/she also indicated he/she should follow a 1500 calorie a day diet, whole grain bread and no sweets. His/her ISP says he/she is to follow a 1500 calorie, low fat, low cholesterol, high fiber diet. Individual Claire's ISP indicated he/she was allergic to cat fur, Erythromycin and penicillin. His/her 2/6/17 physical indicated allergies to penicillin, erythromycin and erythromycin base. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The Program team will review the physical and the ISP document to ensure accuracy of both documents upon receipt. If documents are found to have discrepancies they will document their findings and follow up with the appropriate parties to obtain accurate information |
12/15/2017
| Implemented |
| 2380.176(a) | Individual records, including emergency information and medication administration records, were found unlocked and accessible in the nurse's office that is kept unlocked. | Individual records shall be kept locked when they are unattended. | Effective immediately, the nursing office will remained locked when not in use as well as all records will be maintained in locked cabinets when not in use. |
12/12/2017
| Implemented |
| 2380.181(e)(3)(ii) | Individual #1 9/1/17 assessment did not include his/her current level of communication needs. His/her assessment indicated garbled' communication skills and that him /her makes his/her needs known and socialize with peers.' The assessment did not indicate how he/she would make his/her wants and needs known or socialize with peers since the assessment indicated his/her communication style was garbled.' | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | ¿ It is important to have the assessment include information pertaining to each member¿s communication abilities. Individual #1¿s assessment did not include clear information in regards to individual #1 level of communication. Program Specialist updated the Assessment tool to include additional communication information to address current level and progress (Attachment #3). Individual #1 assessment was updated 12/1/2017 to reflect the updated communication section. All new admissions will have the updated assessment completed within 60 days and annually thereafter. The Program Specialist and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance. |
03/27/2018
| Implemented |
| 2380.181(e)(3)(iv) | Individual #1 requires occasional physical and verbal assistance in the rest room and this was not indicated in his/her 9/1/17 assessment. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Program Specialist updated the Assessment tool to include additional personal needs information to address current level and progress (Attachment #3) |
12/15/2017
| Implemented |
| 2380.181(e)(4) | Individual #1 9/1/17 assessment did not include his/her level of unsupervised time in the restroom or for other activities. His/her assessment only indicated yes' for independent time allowed for bathroom use' and limited independent time allowed for some specialized activities. His/Her assessment also indicated that staff had to check on him/her throughout the year to make sure he/she is continent and completes proper hygiene because a few times throughout the year he/she has been incontinent of bladder. His/her assessment did not indicate his/her supervision needs for time spent in the community with the facility. | The assessment must include the following information: The individual¿s need for supervision. | The program specialist updated the assessment to include amount of time participant can be alone in the restroom (Attachment #3) |
12/15/2017
| Implemented |
| 2380.181(e)(9) | Individual #1 9/1/17 assessment did not include functional limitations. He/She has hearing loss and wears hearing aids throughout the facility so he/she can hear the fire alarms. He/She also uses a walker daily to assist with ambulation concerns. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | ¿ It is important to have the assessment include information pertaining to each members disability, including functional and medial limitations. Individual #1¿s assessment did not include clear information in regards to individual #1 level of disability. The program specialist updated the assessment for individual #1 to include the functional limitations. Individual #1 assessment was updated 12/1/2017 to reflect the updated individual disability section. All new admissions will have the updated assessment completed within 60 days and annually thereafter. The Program Specialist and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance. |
03/27/2018
| Implemented |
| 2380.181(e)(10) | Individual #1 9/1/17 assessment did not include a lifetime medical history. His/her assessment indicated lifetime medical history: clients LMH is on file in his/her chart, created by Elwyn.' | The assessment must include the following information: A lifetime medical history. | It is important to have the assessment include information pertaining to each members life time medical history. Individual #1¿s assessment did not include clear information in regards to individual #1 life time medical history. The program specialist will ensure that a copy of the life time medical is attached to all assessments moving forward. Individual #1 assessment was updated 12/1/2017 to reflect the updated lifetime medical history. All new admissions will have the updated assessment completed within 60 days and annually thereafter, to include the lifetime medical hisotry. The Program Specialist and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.181(e)(12) | Individual #1 9/1/17 assessment did not include recommendations. His/her assessment indicated he/she has no interest in vocational programs, employment, and he/she enjoys his/her time at the senior center. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The program specialists updated the assessment for individual #1 to include recommendations for areas of training, vocational programming and competitive community-integrated employment. (Attachment #4) |
12/15/2017
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1 9/2/16 assessment did not include progress in motor and communication skills. | 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. | It is important to have the assessment include information pertaining to each members to include motor and communication skills. Individual #1¿s assessment did not include progress in motor and communication skills. All assessments after 3/2017 were updated to include progress and growth on motor and communication skills due to another ODP licensing site inspection finding. Individual #1 assessment was updated 12/1/2017 to reflect the updated individual motor and communication skills and progress in these areas. All new admissions will have the updated assessment completed within 60 days and annually thereafter. The Program Specialist and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance. |
03/27/2018
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1 9/2/16 assessment did not include progress in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Program Specialist has updated the assessment tool to include separate section for personal adjustment to discuss last calendar year and current level (attachment #3) |
12/15/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1 9/2/16 assessment did not include progress in 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. | It is important to have the assessment include information pertaining to each members to include progress in socialization. Program Specialist has updated the assessment tool to include separate section for socialization to discuss last calendar year and current level (attachment #3). Individual #1 assessment was updated 12/1/2017 to reflect the updated individual socialization and progress in these areas. All new admissions will have the updated assessment completed within 60 days and annually thereafter. The Program Specialist and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.181(f) | Individual # 1 's 9/2/16 assessment was not sent to any team member. His/her ISP meeting was held 1/10/17. His/her 9/1/17 assessment was only sent to his/her supports coordinator on 9/22/17. Individual #1 team members consisted of supports coordinator, residential specialist, and family members. | 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). | ¿ It is important that the assessment be submitted to team members for review 30 days prior to the ISP meeting. The Program Specialist will send an email attachment to all team members 30 days prior to ISP meeting to include the member¿s annual assessment and print out copies of those email notifications and place them in the member¿s records. The Program Specialist and Center Director were both trained on their responsibility on 3/27/2018 on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
03/27/2018
| Implemented |
| 2380.183(4) | Individual #1 ISP did not include his/her level of supervision needs. According to his/her assessment, he/she could have unsupervised time when in the TV room. However according to staff, he/she needs more supervision in the rest room due to continence issues. The ISP did not include his/her supervision needs for in the community with day program. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | The Program Specialist will update all ODP members ISP reviews to include a community supervision levels per their ISP supervision requirements to be 1:1 or 1:3 while participating in a community outing. |
12/15/2017
| Implemented |
| 2380.184(a)(1)(iii) | A direct support staff from the day program was not in attendance for Individual #1' s annual Individual Support Plan (ISP) meeting. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 2380.186 (relating to ISP review and revision).A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering a service to the individual. | The program specialist will invite the participation of a direct service worker to participate in the ISP meeting. |
12/15/2017
| Implemented |
| 2380.184(c) | Individuals who attended Individual #'s annual Individual Support Plan (ISP) did not date the annual ISP meeting signature sheet. | A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet. | The program specialist will ensure that all team members who are in attendance to the meeting have dated the sign in sheet from Active Day (attachment #2) |
12/15/2017
| Implemented |
| 2380.186(c)(2) | Individual #1 ISP reviews did not review his/her unsupervised time and if he/she utilized it in the past quarter. His/her ISP reviews also did not include a review of his/her community participation. His/her reviews indicated he/she went into the community with residential staff and only listed events the community center had. The ISP reviews did not review if Individual Claire attended any of the community inclusion events at the community senior center. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The program specialist will list special community events that members participate in throughout the year and will then make the team members aware of the participation and become part of the ISP quarterly reviews. |
12/15/2017
| Implemented |
| 2380.186(d) | Individual #1 ISP reviews were not sent to all team members; only sent to supports coordinator within 30 days of completion. His/her team members included residential, family and supports coordinator. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The program specialist will share ISP reviews with all team members within 30 days of completion of the review, team members include residential, family and supports coordinator |
12/15/2017
| Implemented |
| 2380.186(e) | Individual #1's team was not offered the option to decline his/her ISP review information | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The program specialist will list team members on ISP review at which time will ask if they would like to receive a copy of the ISP review. If team members are not in attendance program specialist will contact them via phone to see if they would like to receive a copy, by placing a yes or no by their name. (Attachment #1) |
12/15/2017
| Implemented |