| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(c) | Staff #2 had 21.25 training hours completed in training year 1/01/2015 to 12/31/2015. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | : Staff Training Hours will be monitored every 3 months and shared with employee and supervisor to ensure staff are tracking hours. Trainings will be offered in-house on a regular basis and posted on a quarterly calendar distributed to all staff so that they may register and attend in order to obtain pertinent hours. On-line training opportunities will also be made available to all staff. In addition to quarterly reports, staff will be given a final transcript of their training hours one month prior to end of training year so that they and their supervisor can ensure that all training hour requirements can be met prior to end of training year. |
07/15/2016
| Implemented |
| 2380.53(a) | Poisons were unlocked in the Job Coach's office, including White-out and Derma-Gel Hand Sanitizer, which were labeled "toxic if ingested."
Poisons, including Febreeze Air Effects, Derma-Gel Hand Sanitizer and Derma Sil Sensitive Skin Lotion, were found unlocked in the program area.
| Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The Poisons were immediately removed from access of individuals and locked with other poisonous products. Memo was issued to all Day Program staff, including Job Coach re: doing a daily visual check of program area to ensure that all products that have "contact poison control" on the label are to be locked at all times as not all individuals in the program can safely handle poisons. Memo reviewed with all staff for retraining purposes in 6/2016 (attachment #14). Reminder signs were posted in facility. Day Services Manager and Director will complete physical site inspections on a monthly basis and document on Facility Site review checklist (attachment # 9). Any/all issues found with compliance will be immediately addressed at the time of discovery and appropriate follow up will occur with the program supervisor and/or staff as needed. |
06/23/2016
| Implemented |
| 2380.69(f) | A toilet used by the program area is located in the first aid area; privacy is not provided by partition, door or curtain. | Privacy shall be provided for all toilets by partitions, doors or curtains. | On 8/4/2016, the 1st aid area was relocated from restroom to another area of the program in the rear of the building away from the toilet and away from the 2 main activity rooms so as to provide privacy. The 1st Aid area is no longer shared with restroom space. The new 1st Aid area is equipped with sliding partition doors that will offer the required privacy when needed. (attachment # 13). |
08/04/2016
| Implemented |
| 2380.70(a) | The first aid area is shared with a bathroom used by the program area and is not separated by partition or privacy screen. | The facility shall have a first aid area that is separated by partition or privacy screen from program areas. | On 8/4/2016, the 1st aid area was relocated from restroom to another area of the program in the rear of the building away from the toilet and away from the 2 main activity rooms so as to provide privacy. The 1st Aid area is no longer shared with restroom space. The new 1st Aid area is equipped with sliding partition doors that will offer the required privacy when needed. (attachment # 13). |
08/04/2016
| Implemented |
| 2380.82 | Several doors in the building had locking mechanisms that required a key or code that many staff did not have access to and would not be able to open in the event of a fire or emergency. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | Three egress doors are installed with panic bars/alarms which are on a 15 second delayed opening to help prevent individuals from eloping without being noticed. When doors are pushed, panic alarm will sound and door will release to open within 15 seconds to exit. When fire alarms sound, doors release for exit immediately and there is no 15 second delay. This is not considered an obstruction from being able to exit as the site is deemed as a slow evacuation site by a Fire Safety Professional and permitted a 7 minute evacuation. (attachment # 10) .All doors equipped with this panic bar/alarm were checked by the Alarm Company who installed them on 7/12/2016 and were found to be operating properly (attachment # 11). All staff were trained on how the doors operate in June 2016 and a sign to this effect has been posted at all the doors (attachment # 12). |
07/12/2016
| Implemented |
| 2380.85 | Yankee Candle Sun and Sand aerosol spray, which was labeled flammable, was stored near the heating/air conditioning unit. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. | The Combustible product was immediately removed from the HVAC closet. Memo was issued to all Day Program staff re: doing a daily visual check of program area to ensure that combustibles are stored away from heat and electric sources. Memo reviewed with all staff on 7/8/2016 for retraining purposes (attachment # 8). Day Services Manager and Director will complete physical site inspections on a monthly basis and document on Facility Site review checklist (attachment # 9). Any/all issues found with compliance will be immediately addressed at the time of discovery and appropriate follow up will occur with the program supervisor and/or staff as needed. |
07/08/2016
| Implemented |
| 2380.111(b) | Individual #4's annual physical examination on 12/21/2015 was signed by the physician but not dated. | The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | Doctor was contacted and dated physical for date it was completed as per their records (attachment # 6). Issue could not be addressed with program specialist, as the assigned program specialist at the time is no longer with the agency. However, all Program Specialists were reminded to screen all documents that they have been completed in their entirety prior to filing in client chart. All Program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with requirements, including those pertaining to annual physicals. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
06/20/2016
| Implemented |
| 2380.111(c)(8) | Individual #1's annual physical examination did not contain information documenting the individual's physical limitations. | The physical examination shall include: Physical limitations of the individual. | : Doctor was contacted and completed missing information and re-stamped document on 6/20/2016 (attachment # 7). Program Specialist was reminded via a note to her HR employment file of the importance of screening all documents that they have been completed in their entirety prior to filing in client chart. All Program Specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
06/20/2016
| Implemented |
| 2380.113(a) | Staff #1's date of hire was 3/07/2016 and the date of the physical examination was 4/20/2016. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | After reviewing HR files after licensing visit, it was discovered that the pre-employment physical was completed on 4/15/2015, within one year prior to her employment as required, but document was just not on site at time of inspection. When HR was contacted after licensing, they were able to produce the document. After reviewing it was noted to be in compliance with regulations, and forwarded to licensing representatives on 6/30/2016 (attachment # 5). All required documentation for licensing inspections will be on site for future visits. To ensure compliance with such in the future, HR will begin the practice immediately of forwarding all employment credentials to the Program Management at time of hire so that it is available on site. Monthly sample audits of staff files will be completed by IDD Compliance Officer on site to ensure all required staff credentials are on site. |
06/30/2016
| Implemented |
| 2380.181(a) | Individual #3's date of admission was 9/30/2015 and his assessment was completed on 1/05/2016. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Issue was addressed with program specialist, and she was reminded of the importance of completing initial assessments within a 60 day period, and annual assessments within a 365 day period, via a discipline available in her Human Resources file. Moving forward, Interact has incorporated a checks and balance system along with a quality assurance spreadsheet in which program specialist can keep track of when assessments are due. This spreadsheet will be shared with all program specialists on a monthly basis to assure that assessments and other required client records are completed on a timely basis (attachment 000). Additionally, all program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
09/01/2016
| Implemented |
| 2380.181(d) | Individual #2's annual assessment dated 11/18/2015 was not signed or dated by the program specialist. | The program specialist shall sign and date the assessment. | Issue could not be addressed with program specialist, as the assigned program specialist at the time is no longer with the agency. However, assessment was updated on 7/11/2016 and was signed by Program Specialist and individual and dated accordingly (see attachment # 3). In addition, all program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance |
07/11/2016
| Implemented |
| 2380.181(e)(6) | Individual #3's assessment dated 1/05/2016 does not document the individual's ability to safely use/avoid poisons. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Issue was addressed with program specialist, and she was reminded of the importance of completing all sections of the assessment in its entirety. Program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. Based on prior team discussions as documented in his file, please note that individual was discharged from services 6/30/2016, and an updated assessment was not able to be submitted. |
09/01/2016
| Implemented |
| 2380.181(e)(13)(i) | Individual #2's annual assessment dated 11/18/2015 did not document the individual 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. | Issue could not be addressed with program specialist, as the assigned program specialist at the time is no longer with the agency. However, assessment has been updated to ensure it includes all required components per licensing requirements, including the individual's progress over the last 365 calendar days with regards to health. Individual's assessment was updated 7/11/2016 to include the missing component (attachment # 3 ). All Program Specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
07/11/2016
| Implemented |
| 2380.181(e)(13)(ii) | Individual #3's assessment dated 1/05/2016 does not document the individual's ability to communicate. | 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. | Issue was addressed with program specialist, and she was reminded of the importance of completing all sections of the assessment in its entirety. Program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. Based on prior team discussions as documented in his file, please note that individual was discharged from services 6/30/2016 and as such, his assessment could not be updated. |
09/01/2016
| Implemented |
| 2380.181(e)(13)(v) | Individual #4's annual assessment dated 11/11/2015 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. | Issue could not be addressed with program specialist, as the assigned program specialist at the time is no longer with the agency. However, assessment has been updated to ensure it includes all required components per licensing requirements, including the individual's progress over the last 365 calendar days and current level in RECREATION. Individual¿s assessment was updated 6/27/2016 to include the missing component (attachment # 4 ). All Program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
06/27/2016
| Implemented |
| 2380.181(e)(13)(vi) | Individual #4's annual assessment dated 11/11/2015 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. | Issue could not be addressed with program specialist, as the assigned program specialist at the time is no longer with the agency. However, assessment has been updated to ensure it includes all required components per licensing requirements, including the individual's progress over the last 365 calendar days and current level in community integration. Individual¿s assessment was updated 6/27/2016 to include the missing component (attachment # 4). All Program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
06/27/2016
| Implemented |
| 2380.181(f) | Individual #3's assessment dated 1/05/2016 was not sent to team members prior to the ISP meeting which was held 1/22/2016. | 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). | Issue was addressed with program specialist at which time she was reminded of the importance of completing assessments 30 days prior to ISP meeting, and documenting that it was sent to the team at that time. Additionally, all program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. Based on prior team discussions as documented in his file, please note that individual was discharged from services 6/30/2016, so there is nothing to submit. |
09/01/2016
| Implemented |
| 2380.183(4) | Individual #3 has 1:1 supervision and does not have a fading plan. | 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. | Based on prior team discussions as documented in his file, please note that individual # 3 was discharged from services 6/30/2016, and thus a fading plan cannot be submitted. However, a fading plan was developed by the Behavior Therapist/Program Specialist for another individual in the sample (individual# 4) who receives 1:1 staff support (attachment # 1). Staff were trained in the implementation of this plan in 8/2016. (attachment # 2 ). Documentation of progress will be noted in quarterly reviews of ISP by the Program Specialist. All Program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with requirements, including the need for a fading plan for anyone receiving 1:1 staffing. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
08/10/2016
| Implemented |
| 2380.185(b) | Individual #3's monthly and 3-month ISP documentation does not implement strategies to track progress towards the outcome of "Relationships" identified in the ISP. Individual #4's monthly and 3-month ISP review documentation does not implement strategies to track progress toward the outcome "Community Involvement" identified in the ISP. Individual #5's monthly and 3-month ISP documentation does not implement strategies to track progress towards the outcome "Skill Building" as identified in the ISP. | The ISP shall be implemented as written. | Based on prior team discussions as documented in his file, please note that this individual was discharged from services 6/30/2016, thus there is no submission with this POC for this individual. However, measurable goals related to ISP outcomes were developed for other individuals and implemented (attachment A). Program Specialists were retrained on writing goals that measure progress of ISP outcomes on 7/6/2016 (attachment B). Progress in measurable terms will be documented in monthly summaries and quarterly reviews by the Program Specialist. All Program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with these requirements. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance |
07/11/2016
| Implemented |
| 2380.186(a) | Individual #4's 3-month ISP documentation was dated 6/12/2015; next 3-month ISP documentation was dated 10/14/2015. Individual #5's date of admission was 2/02/2016 and a 3-month review of the ISP was not completed. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP. | Issue could not be addressed with program specialist, as the assigned program specialist at the time is no longer with the agency. Moving forward, Interact has incorporated a checks and balance system along with a quality assurance spreadsheet in which program specialist can keep track of when quarterly's are due. Sample attached (attachment 000). This spreadsheet is shared with all program specialists on a monthly basis to assure that quarterly summaries and other required client records are completed on a timely basis. Additionally, all program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance. |
09/01/2016
| Implemented |
| 2380.186(b) | Individual #2's 3-month reviews of the ISP dated 9/30/2015 and 12/31/2015 were not signed by the program specialist.
Individual #3's 3-month ISP documentation dated 3/22/2016 and 12/22/2015 was not dated by the individual. Individual #4's 3-month ISP documentation dated 6/12/2015 was not signed and dated by the program specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Issue could not be addressed with program specialist, as the assigned program specialist at the time is no longer with the agency. However, all program specialists will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance. Furthermore, to ensure compliance, IDD Compliance Officer will complete monthly client chart audits on a sample population. Full client chart audits will also be completed at management level on a semi-annual basis as further assurance to licensing compliance |
09/01/2016
| Implemented |
| Article X.1007 | OAPSA (ARTICLE X) Intercommunity Action is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 , 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #3 was hired on 3/15/2016; the criminal history check was requested on 3/15/2016. | 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. | Interact will complete background checks prior to date of hire as required, or delay hire date as needed. To ensure Interact's Human Resources Department is aware of this requirement, Interact's VP for IDD Services reminded Interact's VP for Human Resources on 6/20/2016 via telephone and via email that background clearances for new hires must be submitted prior to hire date, or hire date must be delayed. In addition, credentials such as background clearances are to be shared with hiring supervisor by HR Department prior to orientation to ensure compliance, or hire date will be delayed. Routine staff file audits of a sample population will occur by the IDD Compliance Officer on a monthly basis to ensure this requirement is understood and being met. Any issues will be addressed immediately with the Human Resources VP and CEO as needed. |
06/20/2016
| Implemented |