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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(4) | Individual #1's physical examination, completed 6-3-2015, did not include a vision and hearing screenings. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Regarding POC for individual #1 in reference to 2380.111 c (4), Community Living Care utilizes a physical form that contains and meets all criteria listed in 2380 (a), (b) and (c 1-11). (See attached) Community Living Care also developed and implemented the following check list to insure that ALL components of the annual physical form are filled out for every physical form received regardless of whether or not it is a Community Living Care physical form. (See attached checklist) As your records indicate, this issue was caught immediately by the program director during the intake process. Attempts to correct the omission on the other form were unsuccessful. The program director neglected to deny start of services to the new service participant. In the future, services will be denied until the omission is corrected. The program director will be counseled/trained on the necessity to deny/suspend provision of services anytime there is a discovery of noncompliance with any state required documentation. This training will be completed by April 24, 2016. [Individual will obtain a vision and hearing screening at the regularly scheduled annual physical examination or sooner if possible. Immediately, the Director or COO will review all Individuals' current physical examinations to ensure all required information is included and will immediately obtain missing information including vision and hearing screenings. The director will review all initial and annual physical examinations prior to entering into the individuals' records to ensure all required information is present. Documentation of trainings and reviews shall be kept. (AS 4/25/16)] |
04/24/2016
| Implemented |
| 2380.111(c)(5) | Individual #2 had a Tuberculin skin testing with negative results on 3-29-13, and the next again on 7-22-2015. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Regarding POC for individual #2 in reference to 2380.111 c (5), Community Living Care utilizes a physical form that contains and meets all criteria listed in 2380 (a), (b) and (c 1-11). (See attached) Community Living Care also developed and implemented the following check list to insure that ALL components of the annual physical form are filled out for every physical form received regardless of whether or not it is a Community Living Care physical form. (See attached checklist) As your records indicate, this issue was caught immediately by the program director and attempts to correct the omission were unsuccessful. The program director neglected to terminate services until such time as the TB test could be completed. In the future, services will be denied until the test is completed. The program director will be counseled/trained on the necessity to deny/suspend provision of services anytime there is a discovery of noncompliance with any state required documentation. This training will be completed by April 30, 2016. [Immediately, the program director will develop and implement a tracking system for Individuals' annual physical examinations including Tuberculin testing to allow for sufficient notification for Individuals to complete physical examinations including Tuberculin testing within required timeframes. Program Director will document completion of physical examinations including Tuberculin testing and follow up on completion and notification of Individuals of physical examinations including Tuberculin testing to ensure timeliness. At least quarterly reviews of the tracking system shall be completed to ensure timely notification and completion of physical examinations including Tuberculin testing. (AS 4/25/16)] |
04/24/2016
| Implemented |
| 2380.111(c)(6) | Individual #1's physical examination, completed 6-3-2015, did not address communicable disease; therefore compliance could not be measured. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | Regarding POC for individual #1 in reference to 2380.111 c (6), Community Living Care utilizes a physical form that contains and meets all criteria listed in 2380 (a), (b) and (c 1-11). (See attached) Community Living Care also developed and implemented the following check list to insure that ALL components of the annual physical form are filled out for every physical form received regardless of whether or not it is a Community Living Care physical form. (See attached checklist) As your records indicate, this issue was caught immediately by the program director during the intake process. Attempts to correct the omission on the other form were unsuccessful. The program director neglected to deny start of services to the new service participant. In the future, services will be denied until the omission is corrected. The program director will be counseled/trained on the necessity to deny/suspend provision of services anytime there is a discovery of noncompliance with any state required documentation. This training will be completed by April 30, 2016. [Individual #1 will obtain regularly scheduled (or sooner) annual physical examination to include communicable diseases. Immediately, the Director or COO will review all Individuals' current physical examinations to ensure all required information is included and will immediately obtain missing information including communicable diseases. The director will review all initial and annual physical examinations prior to entering into the individuals' records to ensure all required information is present. Documentation of trainings and reviews shall be kept. (AS 4/25/16)] |
04/24/2016
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.173(1)(v) | The records for Individual #1, Individual #2, and Individual #3, do not have a dated photograph. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | In accordance with plan of correction for non-compliance with 2380.173(1)(v) the director/program specialist will date the photos on the assessments for individuals #1,#2 and #3. This change will be made immediately and the director/program specialist will review and receive additional training on the specific regulation with his supervisor. (See accompanying training signature page) Prior to the next licensing cycle this manager will review individual records to ensure that all photographs are in fact dated. |
04/01/2015
| Implemented |
| 2380.181(d) | Individual #2's assessment, dated 12/11/13, was not signed by the Program Specialist. | The program specialist shall sign and date the assessment. | In accordance with plan of correction for non-compliance with 2380.181(d) the director/program specialist will sign the assessment for Individual #2 dated 12/11/13. This change will be made immediately and the director/program specialist will review and receive additional training on the specific regulation with his supervisor. (See accompanying training signature page) Prior to the next licensing cycle this manager will review individual records to ensure that assessments do in fact include signature(s). |
04/01/2015
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(4) | A physical examination of Individual #1 on 11-1-12 did not include a vision screening. Fully implemented - cs - 2/26/13 | (c) The physical examination shall include:(4) Vision and hearing screening, as recommended by the physician. | A vision screening for individual #1 was completed on February 21st, 2013. The parent/guardian for individual #1 was contacted on February 20th, 2013. The regulatory annual requirements for physical well being (in particular, vision screening) were reviewed with the parent/guardian at that time. Agency physical examination form was revised to ensure that vision screening section and all other required information is found on the form as per regulation 2380.111 (a) (b) and (c 1-11). A checklist was developed to be completed for every physical examination form that enters the facility in the future to ensure all required annual screenings and other information is present and completed on each form.
The staff responsible for reviewing physical examination forms at the facility on 9th street, (Program Director) was trained on the implementation of the new checklist. The program director will be responsible for ensuring the consistent implementation of the plan of correction. All physical forms will be reviewed upon receipt by the program director.
Supporting Documentation submitted to inspector included:
Copy of programs revised individual physical examination form showing vision screening section present on form.
Individual #1¿s documentation from vision screening on February 21st, 2013.
Copy of checklist developed from 2380 regulations to be completed and attached to each physical form entering the program.
Copy of sign in sheet from training on proper implementation of checklist and individual physical examination form review.
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02/20/2013
| Implemented |
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