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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(i) | The windows in Individual #1's bedroom did not have drapes, curtains, shades, blinds or shutters. [Repeat violation 4/29/16] | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Individual Corrective Action Plans:
6400.81(i) Individual #1 now has curtains available to him in his room. They are now hung on tension rods so that they can easily be put up and will not cause harm to Individual #1 or walls when/if he pulls them down. Team is updating his ISP to include that they are available to him in his room; that staff will hang them and should Individual #1 pulls them down they will be available to be hung (stored in his closet) and staff will periodically attempt to rehang after each occurrence of him removing them. (pictures and the ISP section will be submitted by July 31, 2017) Program Specialist and Supervisor of Fulton will receive additional training on the 6400.81 regulation requirements.
(training content and verification of completion will be submitted by July 31, 2017)
Systemic Corrective Action Plan:The remaining homes were monitored for compliance with 6400.81(i) ) and found to be in compliance. No systemic Corrective Action Plan necessary. [Within 30 days of receipt of the plan of correction, the program specialist (along with plan team member as appropriate) shall develop an outcome/plan for Individual #1 to have drapes, curtains, shades, blinds or shutters on the bedroom windows if Individual #1 removes the window treatments. Outcome/Plan shall include detailed staff instructions and trainings. Documentation of outcome, trainings shall be kept. (AS 7/11/17)] |
06/23/2017
| Implemented |
| 6400.81(k)(6) | Individual #2's bedroom did not have a mirror. [Repeat violation 4/29/16] | In bedrooms, each individual shall have the following: A mirror. | Individual Corrective Action Plans: 6400.81(k)(6) DB now has a mirror available to him in his bedroom. Currently it is in a dresser drawer. A new mirror will be purchased to mount on the back of his bedroom door. (pictures will be submitted by July 31, 2017) Program Specialist and Supervisor of Fulton will receive additional training on the 6400.81 regulation requirements. (training content and verification of completion will be submitted by July 31, 2017)Systemic Corrective Action Plan:
The remaining homes were monitored for compliance with 6400.81(k)(6) and found to be in compliance.
No systemic Corrective Action Plan necessary.[Immediately and continuing at least monthly, a designated staff person shall check all community homes to ensure all required bedroom items including a mirror are present. At least quarterly for 1 year, the program specialist shall complete an onsite check of each home to ensure all bedrooms have all required items. Documentation of onsite monitoring shall be kept. (AS 7/11/17)] |
06/23/2017
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | Per Individual #1's assessment, completed 12/4/16, when Individual #1 is angry, s/he "will refuse to do an activity or task; when extremely angry will clap hands violently-can be aggressive." Beginning in November 2016, Individual #1 was withdrawn and would isolate in his/her bedroom when Direct Service Worker #2 was working in the home. Individual #1 would hit his/her fist into his/her hand and repeatedly say Direct Service Worker #2's is bad when Direct Service Worker #2's name was mentioned. On 12/6/16, Direct Service Worker #2 told a co-worker that "[Individual #1] is starting [his/her] shit again." From 12/10/16 to 12/11/16, Individual #1 refused showers and meals when Direct Service Worker #2 was working in the home. On 12/12/16, while Direct Service Worker #1 was on the telephone with Direct Service Worker #2 who was working alone in the home, Direct Service Worker #2 said "[Individual #1 is in one of [his/her] moods. I'm sick of listening to [him/her]." Direct Service Worker #2 slammed his/her hand down on the table and said to Individual #1, "You're not getting any pop." | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | Residential Director (Barb Kowalsky) and Program Specialist (Carina Miller) provided retraining to the staff reporter of the incident (staff #1) on the importance of reporting questionable interactions and his observations of mounting frustration of peer. Timely reporting would have prevented the continuation of abuse. This Plan of Correction was completed on January 6, 2017.
Target Staff (staff #2) received a disciplinary action, which included suspension for 7 days without pay. This POC was completed 12/28/2016 by HR Director (Carol Artis) and Residential Director (Barb Kowalsky).
Staff #2 was provided additional retraining on Positive Approaches. This POC was completed on January 3, 2017 by Residential Director (Barb Kowalsky).
Staff #2 was relocated to a different residential site on 12/28/2016. Staff #2 worked all shifts as a second staff person for 3 months. At that time the Supervisor (Wendy Witherow) completed a review of Staff #2¿s interactions with the ladies she supports at the Meadowbrook site indicating Staff #2¿s interactions are appropriate and person centered. This POC was implemented from 12/28/2016 ¿ 3/31/2017 by Residential Director (Barb Kowalsky) and Residential Scheduling Staff (Charlotte Carrozza and Jackie Kolman). |
04/22/2017
| Implemented |
| Article X.1007 | An administrator or employee who has reasonable cause to suspect that a recipient between the ages of 18-59 with a disability is a victim of abuse, neglect, exploitation or abandonment shall immediately make a report in accordance with Older Adult Protective Services (OAPSA) Law (35 P.S. 10225.701 - 10225.707) and 6 Pa. Code 15.21 - 15.27 (relating to reporting suspected abuse) and comply with the requirements regarding restrictions on staff persons. On 12/21/16, at approximately 12:00PM, Direct Service Worker #1 reported to the program specialist that on 12/13/16, while speaking with Direct Service Worker #2 on the telephone, Direct Service Worker #2 said "[Individual #1's] in one of [his/her] moods. I'm sick of listening to [him/her]." Direct Service Worker #2 then slammed his/her hand down onto the table and told Individual #1 "you're not getting any pop." | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Residential Director (Barb Kowalsky) provided training to Program Specialists on January 6, 2017. Training topic was the Reporting requirements for APS (Adult Protective Services Act
Content included a Review of the PA Dept of Human Services Instructions and powerpoint for reporting requirements. These requirements are to protect residents of the Commonwealth between the ages of 18-59. In general: ¿An administrator or employee who has reasonable cause to suspect that a recipient is a victim of abuse, neglect, exploitation or abandonment will immediately make an oral report to the Statewide Protective Services Hotline at 1-800-490-8505. Within 48 hours of an oral report written report will be sent to Liberty Heatlhcare.¿ Additional reporting requirements as required by the Adult Protective Services Law were reviewed. [Within 60 days of receipt of the plan of correction and continuing at least annually, all staff person working with individuals in the community homes shall receive the aforementioned training by the residential director to ensure all staff persons who have reasonable cause to suspect that a recipient between the ages of 18-59 with a disability is a victim of abuse, neglect, exploitation or abandonment shall immediately make a report in accordance with OAPSA an APS laws. Documentation of training shall be kept. (AS 4/21/17) |
04/22/2017
| Implemented |
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