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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(a) | Section 24.8.6 of your Management of the Personal Assets of ID Program Individuals policy titled Cash Shortages states that "if the financial report shows a cash shortage of $5 or less, the shortage is absorbed by the individual." The individual is not responsible for the inadequate tracking of monies by the agency and cannot be required to pay for shortages on the financial ledger. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for advising the individual concerning the use of funds and property. | The language of this policy was reworded on 6/10/2022 to state that individuals are never responsible for Cash Shortages. All cash shortages will be absorbed by the provider agency. |
06/13/2022
| Implemented |
| 6500.24(b) | Section 24.5 of your Management of the Personal Assets of ID Program Individuals policy titled Expenditures Allowed from Individuals includes a list of things that "personal funds of the individuals may be used for." Individuals must be allowed to spend their funds on whatever they choose, they are not to have restrictions. | The policy may not prohibit or interfere with the individual's right to manage the individual's own finances. | "The language in this policy was updated on 6/10/2022 to provide additional clarification. The phrase, ""Expenditures Allowed From Individuals"" has been changed to ""Common Expenditures From Individuals"". The phrase, ""The personal funds of individuals may be used for the following purposes:"" to ""The personal funds of individuals may include but not limited to:"" 1.Room and board and other program fees
2.Fixed assets, such as bedroom furnishings, televisions, stereos, etc.
3.Recreational supplies, such as games and recreational equipment
4.Personal supplies and services, such as toothbrushes, toothpaste, combs, haircuts, etc.
5.Clothing
6.Recreational activities, such as out-of-home meals, snacks, movies, etc.
7.Medical, dental and other professional services
8.Insurance policies and burial accounts" |
06/13/2022
| Implemented |
| 6500.24(d)(2) | The March PEX ledger for individual #1 was missing a disbursement in the amount of $12.69 from the account which resulted in an incorrect balance. Each subsequent month was signed off by staff as being reconciled but the missing disbursement was not addressed until licensing brought the discrepancy to providers attention. | An up-to-date financial and property record shall be kept for each indivudal that includes the disbursements made to or for the individual. | The ledger has been corrected and all receipts are present and accounted for. The PEX card monthly statement for March 2022 has been included to show that the beginning and ending balances as well as all transactions match the ledger. |
06/13/2022
| Implemented |
| 6500.24(e)(1) | Provider has 1 PEX account that funds for more than 1 individual are deposited into and then withdrawn and put onto a separate card for each individual. Individual funds should be deposited and withdrawn from individual accounts and not a joint account. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: a separate record of financial resources including the dates and amounts of deposits and withdrawals. | An annual financial report is being provided to show separate accounting of a variety of income and expense classes, interest-bearing and non-interest bearing accounts, and PA ABLE accounts per individual. This spreadsheet was exported from QuickBooks to show that the funds of each individual are managed separately from all other individuals. |
06/13/2022
| Implemented |
| 6500.24(e)(3) | The 2/17/22 purchase by individual #1 was not listed on the February PEX Card ledger.
And
Section 24.8.5 of your Management of the Personal Assets of ID Program Individuals policy titled Documenting Expenses states "Receipts are not required for haircuts, out-of-home snacks (Ice cream cones, soda, etc.). Recreational activities (movies, swimming, amusement parks, etc.) and other similar expenses for which receipts are not normally given. However, the expense is recorded on in-house receipts." Receipts are required for all purchases over $15. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by family members or agency staff. | The ledger has been corrected and all receipts are present and accounted for. The PEX card monthly statement for February 2022 has been included to show the beginning and ending balances as well as all transactions match the ledger. |
06/13/2022
| Implemented |
| 6500.109(g) | All the fire drills, except the sleep drills, occurred between 3:30pm-5:30pm. The regulations require that the drills be completed during the day and the nighttime hours. There were no drills completed during the daytime hours.
*also, both sleep drills occurred at 12:30am. Sleep drills should also be held at various times between 12am-6am.
**even if they only complete the fire drills once every 6 months, we will still expect to see one completed in the AM hours and one conducted in the PM hours, and the sleep drills conducted at different times each time it is completed as well. | Fire drills shall be held on different days of the week and at different times of the day and night. | Lisa Raab will be retrained by 6/24/2022, on the expectations of completing fire drills at different times of the day and on different days of the week. |
06/24/2022
| Implemented |
| 6500.110(c) | There is no written record verifying that the FLP providers husband attended the annual fire safety training. | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). | Staff will be retrained on annual fire safety training by 6/24/2022. |
06/24/2022
| Implemented |
| 6500.124 | Both Ophthalmology appointments held in 2020 and in 2021 notate that individual #1 has crusting of the eyelids/eyelashes and Dr. recommended using a cleaning solution and for the eyes to be cleaned daily. FLP states that soap and water is used, however, there is no documentation or tracking sheets to demonstrate that this is occurring daily.
It is also recommended that either purchase an actual 'cleanser' suitable for this health issue or contact the Ophthalmologist and have them indicate in writing, that soap and water is an acceptable form of cleansing. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. | Individual Ophthalmologist has been contacted to determine type of cleanser to use or to get written approval that soap and water is acceptable. The physician was to fax instructions to the Provider's office on Friday, 6/10/2022. The Provider has requested the faxed recommendations again on 6/13/2022 and will continue to follow-up until received. The Provider will add the eye care health promotion to individual MAR, including the prescribed or recommended cleanser, upon receipt of the orders. |
06/24/2022
| Implemented |
| 6500.34(a) | Individual #1 signed the information of rights form on 10/18/20 and not again until 2/11/2022. | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | On 6/09/2022, all Program Specialists were retrained on the annual requirements pertaining to the informing of individual rights and the process to report a rights violation. |
06/09/2022
| Implemented |
| 6500.136(a)(11) | Individual #1's MAR contained a medication prescription of, "Levonor-ETH Estrad 0.5-0.03". The MAR did not contain the dx or purpose for this medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | On 5/26/2022, the MAR was updated to include the purpose for the medication:. |
06/15/2022
| Implemented |
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|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(e)(1) | Individual #1 has a debit card for personal spending, called a "PEX card." According to the individual's bank account ledger, $75 was added to her PEX card on 12/21/18. The individual has a PEX card ledger that ends on 12/18/18 with $35.27 left on the card, and another ledger that starts on 12/26/18 with $60 added to the previous balance of $35.27; totaling $95.27 on 12/26/18. However, $75 was added to the card on 12/21/18 and $60 was not added on 12/26/18. The balance as of 12/26/18 should have been $110.27 instead of the documented $95.27. The corrected total of money on the PEX card was not adjusted to accuracy until 2/6/19.
The individual's March 2019 PEX card ledger brought forth the previous balance of $72.43 and added $60 to the account on 3/5/19. According to the individual's bank account ledger, the PEX card was funded with $60 on 2/28/19, 3/14/19, and 3/28/19 on each occasion. According to the individual's PEX card ledgers from 2/28/19-4/2/19, $60 was only added into the account on 2 separate occasions, not three. The additional $60 was not added onto the PEX card ledger until 4/30/19.
The individual's July 2019 PEX card ledger that documents transactions of the card from 6/26/19-7/24/19, lists two withdrawals. Those withdrawals were on 7/19/19 for $9.88 at Walmart and 7/24/19 for $11 at Ruby Tuesday. The ending balance on 7/24/19 was recorded as $90.49. However, the balance brought forward to the next PEX ledger for August 2019 was $101.40 without an explanation for the monetary discrepancy. According to the PEX card balance on 8/21/19, she had $72.44 in her card account. However, there should have been $61.53 since the incorrect balance was brought forward on 7/23/19. The balance for the year has been off since then.
The individual's September 2019 PEX card ledger records a deduction of $49.99 for Gabe's department store. The ledger and the attached receipt do not record a date of purchase when the money was deducted from the account.
The hand-written September 2019 PEX card balance listed $56.06 as the ending balance on 10/1/19. However, the electronic PEX card ledger reviewed by the agency for the first time during the inspection today, 10/30/19, listed that $45.15 was the ending balance on 10/1/19.
The hand-written PEX card ledger for October 2019 carried over a previous balance of $89.17 plus $60 loaded onto the card for a total balance of $149.17. According to the electronic PEX card statement, $45.15 was the balance on 10/1/19, $60 was added on 10/2/19, leaving her with a total balance of $105.15; not $149.17. The hand-written PEX card ledger only recorded one receipt for Rite Aid on 10/21/19 for $16.07. According to the electronic PEX card ledger other purchases were also made using the card for the month of October that were not recorded; Walmart on 10/10/19 for $14.55 and Rite Aid on 10/14/19 for $12.34. Receipts were not in the record. The electronic record states that $62.19 is left on the card as of 10/21/19. The hand-written record states that $135.10 is left on the card as of 10/21/19. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: a separate record of financial resources including the dates and amounts of deposits and withdrawals. | 1. Upon transferring funds to an individual¿s PEX card, fiscal staff will make a notation of the month for which the PEX card is being loaded in the memo section of each transaction in Quickbooks. This will allow for more efficient and accurate reconciliation of the accounts when viewing reports from Quickbooks.
2. When processing the new monthly ledger, fiscal staff will log onto the PEX card website and print out the current balance and the previous month¿s activity for the PEX card. Providing the extra documentation will allow fiscal staff and the Family Living Provider the resources needed to insure all transactions have been reported, have been reported in the correct amounts, and to confirm that the beginning balance on the new ledger is correct each month.
3. Previously, the amount loaded onto the PEX card varied between $60 and $75 depending on the number of Wednesdays in the upcoming month. For example, months with 4 Wednesdays required $60 and months with 5 Wednesdays required $75 ($15 per week). Moving forward, the amount loaded onto the PEX card at the beginning of each month will remain consistent throughout the year. Additional funds are available to the individuals upon request.
4. When turning in the previous month¿s ledger, the Family Living Provider will immediately compare the ending balance to the beginning balance of the new ledger. If any discrepancies exist, the Family Living Provider will work with fiscal staff to resolve the issue.
5. The Family Living Provider will call the number provided on the back of the PEX card at least weekly, to insure the balance on the card is correct. In addition, this process will aid in the early detection of fraudulent purchases.
6. The October ledger for individual #1¿s PEX card has been corrected. The beginning balance, each of the three transactions that occurred in October, and the ending balance have all been recorded on the ledger and match the information provided on the statement printed from the PEX card website.
7. The ID team will be retrained on fiscal responsibilities according to regulations and the updated agency fiscal process by Dec 6, 2019.
8. All Program Specialists, Workforce Development & Training Officer, Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Monday at 3pm and Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information. |
12/06/2019
| Implemented |
| 6500.121(c)(14) | Most recent physical dated 3/12/19 for individual #1 had a space for information pertinent to diagnosis in case of an emergency but it was left blank. This is a repeat violation. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 1. As of August 2019, the position of Training & Compliance officer has been restructured into two separate positions: The Workforce Development and Training Officer and the Compliance Officer. The Compliance Officer will be responsible for insuring that the Health Care Coordinator, Program Specialists and Site Coordinators are trained to complete physicals as per regulations
2. The ID team will be retrained on due dates and responsibilities as they pertain to physicals according to regulations by Dec 6, 2019.
3. All Program Specialists, Workforce Development & Training Officer, Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Monday at 3pm and Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
4. The Healthcare Coordinator, Program Specialist and Site Coordinator will be responsible for reviewing each individual¿s physical documentation to insure that all information pertinent to diagnosis is included and that no fields on the form remain incomplete. |
12/06/2019
| Implemented |
| 6500.151(e)(13)(vii) | Most recent assessment for individual #1 dated 1/23/2019 states that the individual "carries a small amount of money in order to make small purchases" but does not define what the limitations of "small amounts" means. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. | 1. As of August 2019, the position of Training & Compliance officer has been restructured into two separate positions: The Workforce Development and Training Officer and the Compliance Officer. The Compliance Officer will be responsible for insuring that Program Specialists are trained to complete assessments as per regulations.
2. An amended assessment has been completed and includes a qualifier for the ¿small amount of money¿.
3. A review will occur for all other individuals¿ assessments and will identify any other qualifiers that will need more specific definitions or descriptions.
4. The ID team will be retrained on requirements as they pertain to assessments and updates to the ISP according to regulations by December 6, 2019.
5. All Program Specialists, Workforce Development & Training Officer, Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Monday at 3pm and Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information. |
12/06/2019
| Implemented |
| 6500.17(a) | There was no self-assessment completed for this home 3-6 months prior to license expiration date of 6/30/19. This was verbally confirmed by the program director. | If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | 1. As of August 2019, the position of Training & Compliance officer has been restructured into two separate positions: The Workforce Development and Training Officer and the Compliance Officer. The Compliance Officer will be responsible for insuring that the self-assessments for all sites are completed annually within the specified time period: 3 to 6 months prior to the expiration date of the agency's certificate of compliance.
2. The ID team will be retrained on due dates and responsibilities as they pertain to self-assessments according to regulations by December 6, 2019.
3. The self-assessments will be distributed and partially completed during a Team Meeting in January 2020. The Compliance Officer will work with the Program Specialists to insure the completion of the self-assessments occurs within the 3-6 months prior to the expiration date of the agency¿s certificate of compliance.
4. Completed self-assessments will be due to the Compliance Officer on March 1 of each year.
5. All Program Specialists, Workforce Development & Training Officer, Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Monday at 3pm and Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information. |
12/06/2019
| Implemented |
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|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(a) | Self-assessment completed on 10/11/18, license expires 6/30/18. | If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | 1. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was completed on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
2. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
7. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. The retraining will include a review of the regulation regarding the self-assessment.
8. The self-assessments will be distributed and partially completed during a Team Meeting scheduled for 2/7/19. The on site assessment portions will be individually completed by Program Specialists throughout the month of February. Completed self-assessments are due to the Program Director on 3/7/19. |
11/21/2018
| Implemented |
| 6500.31(b) | Signed copy of rights was completed on 2/13/17 and not again until 8/20/18. | A statement signed and dated by the individual, or the individual's parent, guardian or advocate if appropriate, acknowledging receipt of the information on individual rights upon admission and annually thereafter, shall be kept. | 1. The previous Lifesharing Program Specialist submitted her resignation effective 4/29/18.
2. The new Lifesharing Program Specialist was assigned 6/1/18.
3. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) is scheduled on 8/2/18. All records (6400, 6500 and 2380) will be up to date by 9/21/18.
4. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
7. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
8. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This will be officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
9. Consents for all individuals are scheduled to go out the beginning of July 2019. This is coordinated by the Administrative Assistant and the Program Specialists. Each year, consents are sent out one month prior than the year before to give ample time for completion within a year.
10. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.45(c) | Staff #1 had first aid training on 2/24/16 and not again until 3/28/2018. | The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter | 1. The Lifesharing provider also works for another agency and is usually unable to attend the trainings that Family Services provides. The other agency provides trainings which she attends and/or completes. The Lifesharing provider then provides Family Services with the proof of training.
2. The Lifesharing provider is certified in Heartsaver First Aid CPR AED training good through March 2020.
3. The Training & Compliance Officer has updated the Lifesharing provider¿s recertification to the list of staff needing First Aid CPR AED training.
4. If the Lifesharing provider does not recertify through her other employer, she will be included in a training class prior to March 2020.
5. Training of staff requirements was originally scheduled to be presented to the Program Specialists, Health Care Coordinator, Training & Compliance Office and Program Director for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.46(b) | Staff ID Training completed on 7/12/17 but no record of the training in 2018, ID training is an annual training requirement. | A family living specialist who is employed by an agency for more than 40 hours per month shall have at least 24 hours of training related to intellectual disability and the requirements specified in this chapter annually. | 1. The Lifesharing provider also works for another agency and is usually unable to attend the trainings that Family Services provides. The other agency provides trainings which she attends and/or completes. The Lifesharing provider then provides Family Services with the proof of training.
2. The Lifesharing provider will be provided with a training packet to complete that includes ID Principles and Values, Family Services Grievance Procedures, Policies & Procedures, Individual Bill of Rights, Quality Management Plan and Civil Rights. This will be completed by 11/30/18.
3. The Training & Compliance Officer has updated the Lifesharing provider¿s training logs.
4. Training of staff requirements was originally scheduled to be presented to the Program Specialists, Health Care Coordinator, Training & Compliance Office and Program Director for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/30/2018
| Implemented |
| 6500.74 | On right side of home there is a cement walkway that extends down a hill into the back yard, accessible from the side door entrance of the home, that does not contain nonskid Surfaces. | Interior stairs and outside steps that are accessible to individuals shall have a nonskid surface. | 1. The maintenance supervisor was out to visit the site on 11/7/18. The walkway is cement but contains large stones and has a rough consistency. There is a paint that contains sand that could be used but the maintenance supervisor does not feel this would remedy the situation as it is not a smooth surface currently.
2. The homeowners have made it known that they most likely will be doing work on their septic system in the spring and will be tearing up the walkway. |
11/07/2018
| Implemented |
| 6500.121(c)(14) | Most recent physical form for Individual #1 dated 3/12/18 under section "info pertinent to diagnosis/treatment in emergency" was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 1. The previous Lifesharing Program Specialist submitted her resignation effective 4/29/18.
2. The new Lifesharing Program Specialist was assigned 6/1/18.
3. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) is scheduled on 8/2/18. All records (6400, 6500 and 2380) will be up to date by 9/21/18.
4. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
7. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
8. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This will be officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
9. Site Coordinators and Program Specialists are responsible for making sure all information is included on physicals.
10. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.153(7)(iii) | On most recent ISP Individual #1 dated 9/23/18 there was no information listed regarding vocational programming. | The ISP, including annual updates and revisions under § 6500.156 (relating to ISP review and revision) must include the following: Assessment of the individual's potential to advance in the following: Vocational programming. | 1. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was completed on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
2. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This will be officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
7. Track changes to the individual¿s ISP were sent regarding vocational programming on 11/8/18 and again on 11/9/18.
8. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.156(a) | ISP quarterly reviews for time period 10/2017- 01/2018 was not signed, quarterly review for time period 01/2018-04/2018 was signed late on 9/21/18, quarterly review for time period 04/2018-7/2018 was signed late on 9/24/18. | The family living specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the family living home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change, which impacts the services as specified in the current ISP. | 1. The previous Lifesharing Program Specialist submitted her resignation effective 4/29/18.
2. The new Lifesharing Program Specialist was assigned 6/1/18.
3. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
4. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
7. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
8. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This will be officially implemented 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
9. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.156(b) | ISP Quarterly review for time period 10/2017-01/2018 is not signed by the individual. | The family living specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | 1. The previous Lifesharing Program Specialist submitted her resignation effective 4/29/18.
2. The new Lifesharing Program Specialist was assigned 6/1/18.
3. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
4. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
7. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
8. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This will be officially implemented 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
9. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.156(d) | ISP quarterly review for the time period 01/18-04/18, 04/18-07/18 was not sent to team 30 days after meeting. | The family living specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | 1. The previous Lifesharing Program Specialist submitted her resignation effective 4/29/18.
2. The new Lifesharing Program Specialist was assigned 6/1/18.
3. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
4. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
7. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
8. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
9. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
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