| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.32(b)(4) | 2017 violation report indicated strobe lights not operable at the facility with many rooms missing the strobe device itself. The 2018 annual inspection also found that the facility was still out of compliance due to missing and inoperable strobe lights throughout the facility. Individual # 2 is deaf. Proper and adequate training was not provided to the program specialist prior to assuming his/her role. Numerous violations demonstrate lack of compliance with chapter regulations | The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Compliance with this chapter. | Marco Protection Systems visited the site on 6/7/18 and performed an annual inspection of the facility and will be installing all required strobe lights throughout the facility. The annual inspection documentation should be available to Kelsch by 6/22/18. The installation will take up to 10 weeks to receive necessary permits and install. In the interim, in order to maintain Individual #2¿s safety at program, the FEP has been adjusted to assign direct care staff to locate Ind. #2, in the event of an emergency or emergency drill, if he/she is not in an area where there is strobe lighting and alert her to the need to evacuate using a flash card that explains the need to exit with her assigned direct care staff. All FACT direct care staff have been trained on the revised FEP by Kelsch¿s Director of Services on 05/23/18 during the program¿s staff meeting and again received training from Kelsch¿s FACT program specialist on the 6/6/18 staff meeting. (See Attachment #1). FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. |
08/17/2018
| Implemented |
| 2380.33(b)(1) | The program specialist did not complete Individual #2'ss assessment. Staff # 4, the program manager completed the assessment. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | Actual Remediation: Program Manager credentials as a Program Specialist provided in attachment, (See Attachment #3). |
06/08/2018
| Implemented |
| 2380.33(b)(18) | No documentation of staff training on Individual # 2's diabetes diagnosis, signs and symptoms of, what to do if staff notice concerning signs and symptoms of diabetes, etc. no training on American sign language so staff can communicate with him/her. Individual # 2 knows ASL according to his/ her record. No documentation of training on individual # 2's 50 fluid ounce daily restriction. The ISP training log for Individual 3 2'sstaff did not indicate a date any of the staff were trained on his/her ISP or which ISP was included in the training (i.e. annual, revision, gen. update). No documentation of training in what snack should be given to individual # 2 at the end of the day to ensure his/ her blood sugar stays stable. Day program staff were not trained on Individual # 2's medications or their side effects as his/her ISP says they should be. ISP says all staff are trained in Individual # 2's communication assessment report and recommendations conducted by ODP prior to working with him/her. The report was completed on 8/1/16 and staff were not trained until 8/22/17 through 3/26/18. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(a), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. Ind. #2¿s Lead direct-care staff, his/her Group Leader, received Insulin training at Riddle Hospital on 5/1/18. and an alternate direct care staff, in the event of the group leader¿s absence, has also received Insulin training at Riddle Hospital on 12/31/17. (Attachment #4) All direct care staff are trained yearly in observing signs and symptoms of diabetic related complications during first aid training. Direct care staff and the FACT Program Specialist were trained by Ind. #2¿s Group Leader on his/her individualized communication abilities as per the ISP, updated 5/24/18, and his/her CAR report, (See Attachment #5). Direct care Staff were trained by FACT¿s Program Specialist on individual #2¿s 50 fluid oz restriction, along with Fluid Intake documentation and have signed and dated documentation of having received training, (See Attachment #6). Direct care Staff have been trained by the FACT Program Specialist on the ISP plan of Ind. #2, updated 5/24/18, and have signed and dated the documentation, see attached documentation, (See Attachment #7). Ind. #2¿s SC has been contacted and the administration of the afternoon snack has been clarified in the ISP, updated 5/24/18, to reflect that Ind. #2 self-administers her snack provided from home. Direct care Staff have been trained on the most current medication list for Individual #2 and have been trained on information pertaining to the medications being taken, (See Attachment #8). Ind. #2¿s SC has been contacted about the discrepancy in the dates of the Communication Assessment and provided documentation of when SC received the finalized CAR Report (See Attachment #5) and then forwarded via email to Francis Washington, Brian Havlik, and Bendu Outland on 7/3/17. Report was discussed at the ISP meeting on 8/8/17. (See Attachment #9) Going forward the Group Leader, or Lead direct care staff, for Ind. #2 and an alternate will continue to receive Insulin Training yearly and this will be tracked by the Training Department. All other Direct care staff will continue to be trained yearly in First Aid course which includes signs and symptoms of diabetic related illness and this will continue to be documented and kept on record. Going forward all new Direct care Staff will be trained by Program specialist on individual #2¿s 50 fluid oz restriction and have signed and dated documentation of having received training. In the future new Direct care staff will be trained by Group Leader on individual #2¿s individualized communication abilities as per the ISP, updated 5/24/18 and CAR report and documentation kept. Kelsch¿s FACT Program Specialist will monitor the training of direct care workers in the FACT program on the content of health and safety needs relevant to each individual in the program. Kelsch¿s Director of Services will ensure direct care staff receive training from FACT Program Specialist and will be responsible for maintaining all documentation of trainings. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which include trainings and documentation of health and safety needs relevant to each individual completed by staff, on a quarterly basis to assure training was completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.36(a) | Staff # 2 was hired on 10/09/17 and began working with individuals on 10/09/17 without prior orientation. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(a), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. Moving forward a revised new Training and Orientation schedule has been put in place (See Attachment #10, Page #3, #20). to ensure that Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Kelsch¿s FACT Program Specialist will monitor the training of direct care workers in the FACT program on the content of health and safety needs relevant to each individual in the program, which includes the FEP. Kelsch¿s Director of Services will ensure direct care staff receive training from FACT Program Specialist for regulatory compliance. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which include trainings and documentation of health and safety needs relevant to each individual completed by staff, on a quarterly basis to assure training was completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.36(c) | Staff # 3 received 20.8 hours of training during the 16-17 training year. | 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. | Going forward direct care staff missing time from work will be required to make up training time to meet regulations prior to returning to working with consumers. Kelsch¿s Training Coordinator will ensure direct care staff receive training all necessary for regulatory compliance and will be responsible for maintaining all documentation of trainings. Kelsch¿s Training Coordinator has examined the training records of FACT direct care staff and will have all direct care staff trained and found all direct care staff currently meet regulatory standards for the 17-18 training year. |
06/08/2018
| Implemented |
| 2380.36(e) | Staff # 3 received fire safety training on 08/24/16 and not again until 09/07/17. | Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(a), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. Moving forward a revised new Training and Orientation schedule has been put in place (See Attachment #10) to ensure that Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or direct care staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Kelsch¿s FACT Program Specialist will monitor the training of direct care workers in the FACT program on the content of health and safety needs relevant to each individual in the program. Kelsch¿s Director of Services will ensure direct care staff receive training from FACT Program Specialist. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which include trainings and documentation of health and safety needs relevant to each individual completed by direct care staff, on a quarterly basis to assure training was completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.36(e) | Staff #2's training record did not include initial fire safety training. Staff # 2 hired on 10/09/17 and received Fire safety training on 01/08/18. | Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(a), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. Moving forward a revised new Training and Orientation schedule has been put in place (See Attachment #10) to ensure that Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or direct care staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Kelsch¿s FACT Program Specialist will monitor the training of direct care workers in the FACT program on the content of health and safety needs relevant to each individual in the program. Kelsch¿s Director of services will ensure direct care staff receive training from FACT Program Specialist. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which include trainings and documentation of health and safety needs relevant to each individual completed by direct care staff, on a quarterly basis to assure training was completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.55(a) | A cooking tray covered in grease and other blacked food particles was found in the kitchen cabinet where the rest of the clean dishes' were stored. | Clean and sanitary conditions shall be maintained in the facility. | Going forward the cleanliness of cooking implements will be done and documented as part of daily chores done by direct care staff and then checked by Program Specialist. Direct care staff were trained on revised chore list and Temperature Check Sheet, including the regulations stipulated procedure for determining temperatures (See Attachment #11). Kelsch¿s FACT Program Specialist will do a physical inspection of the facility in conjunction with review the chore sheet and Temperature Check sheet on a monthly basis. FACT¿s Program Specialist has inspected the facility and the facility is now in compliance with this regulation. |
06/08/2018
| Implemented |
| 2380.55(d) | The trash can in the cafeteria area in the first floor was not covered to prevent the penetration of insects and rodents | Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents. | Trash can was removed, and new trash can with lid purchased. . FACT¿s Program Specialist has provided training to the direct care staff with a walking tour of the facility and review of the applicable physical site regulations, which includes regulation 2380.55(d) that trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents and documented the training. (Attachment #12). FACT¿s Program Specialist has inspected the facility and the facility is now in compliance with this regulation. |
06/08/2018
| Implemented |
| 2380.58(a) | The 2nd floor surfaces not in good repair: two black chairs had rips along the back of the chair exposing the wooden chair frame, holes in the wall of the first aid room, scratches and scrapes in wall/paint near the floor of every room,
-1st floor: blue large mat on the floor ripped at every possible seam of the mat with duct tape, brown reclining chair 2 foot rip that was duct tape holding it together, scratches/scrapes along every wall in the facility, | Floors, walls, ceilings and other surfaces shall be in good repair. | Company Maintenance has been informed of all physical defects found and will have all physical site repairs and painting completed by 8/30/18. Company purchasing agents have been informed of all physical defects found in furniture (mats, chairs, tables, etc.) and will have all furniture replacement completed by 8/30/18. FACT¿s Program Specialist has provided training to the direct care staff with a walking tour of the facility and review of the applicable physical site regulations and documented the training. (Attachment #12) . FACT¿s Program Specialist has inspected the facility and added any necessary additions to the purchasing request such that the facility will be in compliance with this regulation upon completion of renovations and furniture replacement. |
08/30/2018
| Implemented |
| 2380.59(b) | The water in the bathroom of the first floor was 123.3 degrees Fahrenheit | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | Maintenance adjusted water temperature to 120 degrees. Going forward the checking of all temperatures will be done as part of daily chores by direct care staff and documented on a Temperature Checklist. Direct Care Staff were trained on revised chore list and Temperature Check Sheet, including the regulations providing the procedure for determining refrigerator, freezer and water temperatures (See Attachment #11). Kelsch¿s FACT Program Specialist will do a physical inspection of the facility in conjunction with review the chore sheet and Temperature Check sheet on a monthly basis. FACT¿s Program Specialist has inspected the facility and the facility is now in compliance with this regulation. |
06/08/2018
| Implemented |
| 2380.84 | No documentation that an annual fire safety inspection was held for the years 2016, 2017 or 2018. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | Documentation provided was found inadequate. Marco Protection Systems visited the site on 6/7/18 and performed an annual inspection of the facility and will be installing all required strobe lights throughout the facility. The annual inspection documentation should be available to Kelsch by 6/22/18. Kelsch¿s Director of Loss Control will maintain documentation of the date, source and results of the fire safety inspection. |
06/22/2018
| Implemented |
| 2380.87(b) | Individual #2 is deaf and hearing impaired. The second floor program room was not equipped with a strobe light in the first aid room, bathroom, puzzle room, book room, kitchen or cafeteria. The first floor program room was not equipped with a strobe light; back left room where records are kept, cafeteria, first aid area, bathroom, kitchen, and back room/coat room by exit. The first floor main program room was equipped with a strobe light however it did not operate during the fire drill. The previous annual inspection completed at this facility on 3/27/17 indicated that 2380.51; accommodations for physical disabilities was cited. The previous violation report indicated the strobe lights on the fire alarms system did not work in the upstairs lunch room or in the downstairs day program room. Also there were no strobe lights for the fire alarms system in the upstairs or downstairs bathrooms. Individual #4 is hearing impaired.' | If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire. | Marco Protection Systems has visited the site and will be performing an annual inspection of the facility (6/7/18) and will be installing all necessary strobe lights throughout the facility. The installation will take 10 weeks to receive necessary permits and install. In the interim, in order to maintain Individual #2¿s safety at program, the FEP has been adjusted to assign direct care staff to locate Ind. #2, if he or she is not in an area without the appropriate fire safety supports in the event of an emergency or emergency drill and alert her to the need to evacuate using a flash card that explains the need to exit with her assigned direct care staff, (See Attachment #1). All FACT direct care staff have been trained on the revised FEP by Kelsch¿s Director of Services on 05/23/18 during the program¿s staff meeting and again received training from Kelsch¿s FACT program specialist on the 6/6/18 staff meeting. (See Attachment #1). Kelsch¿s FACT Program Specialist will monitor the training of direct care workers in the FACT program on the content of health and safety needs relevant to each individual in the program. Kelsch¿s Training Coordinator will ensure direct care staff receive training from FACT Program Specialist and will be responsible for maintaining all documentation of trainings. |
08/17/2018
| Implemented |
| 2380.89(a) | No documentation that fire drills were held from 03/17-12/17. | An unannounced fire drill shall be held at least once a month. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(a), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. Kelsch¿s FACT Program Specialist will ensure an unannounced fire drill shall be held at least once a month. Documentation of fire drills will be stored in a binder in the Program Specialists office. Kelsch¿s Director of Loss Control will monitor the completion of fire drills by Kelsch¿s FACT Program Specialist and will be responsible for maintaining a copy of all documentation of fire drills. |
06/08/2018
| Implemented |
| 2380.89(c) | Fire drill records for 03/19/18, 02/21/18, 01/26/18 do not include if any problems were encountered. No space on form to report problems. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(c), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of the PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code § 2380 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. (See Attachment #2). A new fire drill record document has been designed and will be implemented for all fire drills. The new form has a space to record problems encountered, (See Attachment #13). Kelsch¿s Director of Loss Control will monitor completion of fire drills by Kelsch¿s FACT Program Specialist and will be responsible for maintaining documentation of drills. |
06/08/2018
| Implemented |
| 2380.89(g) | Fire Drill records for 03/29/18, 02/21/18 and 01/26/18 do not indicate if individuals arrived at the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(g), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of the PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code § 2380 and explained their duties by their immediate supervisor prior to beginning their duties and this training will be signed and dated and documented. (See Attachment #2). A new fire drill record document has been designed and implemented for all fire drills that has a space to record if all individuals arrived at the designated meeting place (See Attachment #13). Kelsch¿s Director of Loss Control will monitor completion of fire drills by Kelsch¿s FACT Program Specialist and will be responsible for maintaining documentation of drills. |
06/08/2018
| Implemented |
| 2380.91(a) | Individual # 2 had fire safety training on 01/11/18 and no documentation of 2017 training. Agency fire safety training sheet did not indicate date of Individual's training. Individual #2 is deaf, can read and write and understands some ASL. Fire safety training not provided in his/her primary mode of communication | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | Ind. #2 was provided written instructions in fire training as per her abilities specified in the CAR report. The Fact Annual Fire Safety Training for consumers has been revised to provide documentation that instruction was given in the individual's primary language or mode of communication. (See Attachment #5). Kelsch¿s Program Specialist trained direct care staff on the revised document on 6/6/18 (See Attachment #14). Kelsch¿s PS has examined the fire training records of the remaining FACT individuals and they are in compliance with this regulation. |
06/08/2018
| Implemented |
| 2380.111(c)(1) | Individual #1's physical dated 08/28/17 did not indicate medical history was reviewed by physician | The physical examination shall include: A review of previous medical history. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(g), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of the PS training will be kept on file, (See Attachment #2). In addition to an initial inspection upon initial receipt of the annual by the Program Specialist, going forward the quarterly review process performed by the Program Specialist will include a review of the annual physical to ensure that it complies 2380 regulations. This physical review form will be completed and implemented by 8/5/18. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include annual physicals, on a quarterly basis to assure the annual physical was completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. A correspondence was sent to Ind. #1¿s Program Specialist requesting the necessary information to make the 8/28/17 physical complete. (See Attachment #15). |
08/05/2018
| Implemented |
| 2380.111(c)(6) | Individual # 2's 10/10/ physical evaluation did not indicate if he/she was free from communicable disease. Indicates Not applicable | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(g), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of the PS training will be kept on file, (See Attachment #2). In addition to an initial inspection upon initial receipt of the annual by the Program Specialist, going forward the quarterly review process performed by the Program Specialist will include a review of the annual physical to ensure that it complies 2380 regulations. This physical review form will be completed and implemented by 8/5/18. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include annual physicals, on a quarterly basis to assure the annual physical was completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. A correspondence was sent to Ind. #1¿s Program Specialist requesting the necessary information to make the 8/28/17 complete. (See Attachment #15). This physical review form will be completed and implemented by 8/5/18. A correspondence was sent to Ind. #1¿s SC requesting the necessary information to make the 10/10/17 complete. The SC has faxed the Doctors office to receive the necessary information. The SC reports the office manager confirmed the doctor would provide the sign information needed. (See Attachment #16). |
08/05/2018
| Implemented |
| 2380.111(c)(9) | Individual # 1's physical dated 08/28/17 does not indicate allergies. Space left blank. | The physical examination shall include: Allergies or contraindicated medication. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380, which includes chapter 2380.89(g), and has received training on the regulations and his role as specified in § 2380.33 by the Director of Services. Signed and dated documentation of the PS training will be kept on file, (See Attachment #2). In addition to an initial inspection upon initial receipt of the annual by the Program Specialist, going forward the quarterly review process performed by the Program Specialist will include a review of the annual physical to ensure that it complies 2380 regulations. This physical review form will be completed and implemented by 8/5/18. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include annual physicals, on a quarterly basis to assure the annual physical was completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. A correspondence was sent to Ind. #1¿s Program Specialist requesting the necessary information to make the 8/28/17 complete. (See Attachment #17). A correspondence was sent to Ind. #1¿s Program Specialist requesting the necessary information to make the 8/28/17 complete. (See Attachment #18). |
08/05/2018
| Implemented |
| 2380.115(1) | No documentation of an emergency medical plan contained in Individual # 2's record. | 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. | Section 8-9 Emergency Procedures from the ATF Policies and Procedures manual specifies an emergency medical plan containing the hospital or source of health care that will be used in an emergency, the method of transportation to be used, and an emergency staffing plan to be used at the facility. (See Attachment #18) |
06/08/2018
| Implemented |
| 2380.115(2) | No documentation of an emergency medical plan contained in Individual # 2's record. | The facility shall have a written emergency medical plan listing the following: The method of transportation to be used. | Section 8-9 Emergency Procedures from the ATF Policies and Procedures manual specifies an emergency medical plan containing the hospital or source of health care that will be used in an emergency, the method of transportation to be used, and an emergency staffing plan to be used at the facility. (See Attachment #18) |
06/08/2018
| Implemented |
| 2380.115(3) | No documentation of an emergency medical plan contained in Individual # 2's record. | The facility shall have a written emergency medical plan listing the following: An emergency staffing plan. | Section 8-9 Emergency Procedures from the ATF Policies and Procedures manual specifies an emergency medical plan containing the hospital or source of health care that will be used in an emergency, the method of transportation to be used, and an emergency staffing plan to be used at the facility. (See Attachment #18) |
06/08/2018
| Implemented |
| 2380.155(a) | Individual # 2 has a 50 ounce fluid per day restriction. No restrictive procedure is in place. The kitchen area on first floor is locked and no restrictive procedure in place. The refrigerator and snack cabinet on the second floor where individual lunches are stored is kept locked without a restrictive procedure plan in place. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to the use of restrictive procedures. | Direct care staff were trained by FACT¿s Program Specialist on 2380 regulations regarding restrictive procedures and have signed and dated documentation of having received training on 6/6/18, (See Attachment 19). All restrictions on food owned by individuals has been removed. Consumer food is no longer kept locked in any areas. Clarification on the fluid restriction placed on Individual #2 has been requested of the SC and we await a determination on whether the restriction of fluids is recommended or required from her physician. (See Attachment #20). FACT¿s Program Specialist will review all individual books and gain the necessary clarifications on any fluid restrictions to bring the program into compliance with this regulation by 8/30/18. |
08/30/2018
| Implemented |
| 2380.171(b)(3) | Individual # 2's record did not contain the name of the person able to give medical consent for emergency treatment. Record indicates NHS Executive director. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Ind. #2¿s SC was contacted, and this discrepancy was corrected in the ISP, updated 5/24/18. (See Attachment #21). FACT¿s Program Specialist will review all individual books and seek any clarifications on emergency information to bring the program into compliance with this regulation by 8/30/18. |
08/30/2018
| Implemented |
| 2380.173(1)(i) | Individual # 2's record did not contain the date of admission to the day program facility. | Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Ind. #2¿s date of admission was received from SC and his/her program book was updated accordingly. (See Attachment #22). FACT¿s Program Specialist will review all individual books and seek any clarifications on the date of admission of any individuals if necessary to bring the program into compliance with this regulation by 8/30/18. |
08/30/2018
| Implemented |
| 2380.173(1)(ii) | Individual # 1's record indicates identifying marks as: wearing glasses. Personally identifiable marks not recorded. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Individual #1¿s records were updated to record personally Identifiable marks that were more detailed and distinctive. (See Attachment #23). Going forward only detailed and distinctive attributes will be used as personally Identifiable marks. ). FACT¿s Program Specialist will review all individual books and seek any clarifications on personally identifiable makes of any individuals if necessary to bring the program into compliance with this regulation by 8/30/18. |
08/30/2018
| Implemented |
| 2380.173(9) | Individual #1's ISP dated 12/07/17 indicates a diet of low cholesterol and a mechanical soft diet. Face sheet states No Special Diet. Physical dated 08/28/17 indicates a low cholesterol diet. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Individual #2¿s Assessment has been rewritten to be more detailed, accurate, and consistent with the ISP, updated 5/24/18. (See Attachment #24). All assessments will be written to be consistent with the goals of accuracy, detail, and consistency. Going forward the Program Specialist will review the dietary information including assessment, physicals, ISP¿s and Eating, Drinking, Swallowing Reports to ensure they are accurate, detailed and consistent. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, physicals, ISP¿s and Eating, Drinking, Swallowing Reports, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.173(9) | Individual # 2's lifetime medical history indicates that he/she is to follow a diabetic diet with no added salt recommended to reduce caloric intake, no concentrated sweets, low fat, low cholesterol, fluid restriction to 50 oz daily. Individual # 2's 10/10/176 physical indicated to follow a diabetic, no concentrated sweets, low fat, low cholesterol fluid restriction to 50 oz daily diet. Individual # 2's ISP states diabetic diet, fluid restriction up to 1500 cc's every 24 hours due to low sodium, recommended to reduce caloric intake, eat foods in fat due to high cholesterol and he/she should eat a snack in the afternoon before leaving day program to keep blood sugar stable. Individual # 2's assessment indicates he/she is supervised at all times at day program, in 1:3 groups and allowed 10 minutes of unsupervised time doing activities or using the bathroom. ISP indicates staffing ratio of 1:2 to 1:6 or in community 1:2 to 1:3 with the day program. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Individual #2¿s Assessment has been rewritten to be more detailed, accurate, and consistent with the ISP, updated 5/24/18. (See Attachment #24). All assessments will be written to be consistent with the goals of accuracy, detail, and consistency. Going forward the Program Specialist will review the dietary information included in assessment, physicals, ISP¿s and Eating, Drinking, Swallowing Reports to ensure they are accurate, detailed and consistent. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessment, physicals, ISP¿s and Eating, Drinking, Swallowing Reports, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(b) | Individual # 1's assessment dated 10/25/17 indicates that he/she is safe around poisons. ISP last updated 01/25/18 indicates that recently (12/17), some concerns were noted over individual # 1 using hygienic products properly. Therefore to assure his safety at this time, all chemicals in the home are now locked. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 2380.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the individual¿s ISP to ensure the consumer¿s assessment is current and accurate and detailed. During this review, if any necessary updates are found the Program Specialist will send a correspondence to the individuals team members including the SC to describe the necessary updates and file the correspondence in the individual¿s program book. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments and ISP, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(d) | Individual # 2's 06/30/17 assessment was not signed or dated by the program specialist. | The program specialist shall sign and date the assessment. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward all ISP review and assessments will be signed and dated by the Program Specialist. Also, the Program Specialist will send an email correspondence to the individual¿s team members, including the SC, to confirm with the team the date that an assessment or ISP review has been sent out and this email will include a space to decline to receive future documents (where applicable). The correspondence and any replies declining documents will be filed in the individual¿s program book. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(3)(i) | Individual # 2's 6/30/17 assessment did not include his/her functional skills. The assessment said he/she needs someone to show him/her how to do new skills | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Acquisition of functional skills. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Individual #2¿s Assessment has been rewritten to be more detailed, accurate, and consistent with the ISP, updated 5/24/18. (See Attachment #24). Going forward the Program Specialist will review the individual¿s acquisition of functional skills within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure the assessment and ISP have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(3)(ii) | Individual # 2's 6/30/17 assessment did not include his/her communication skills. He/She is nonverbal and deaf and his/her assessment did not indicate this. He/she is also communicates with ASL and this was not included in her assessment. His/Her assessment did not include his/her ability to communicate his/her wants, needs, or pain management. The assessment only indicates what staff must do to communicate with him/her (i.e. tap on shoulder for lunch and when time to leave.) According to the ISP, he/she can read and write and communicates that way sometimes. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Individual #2¿s Assessment has been rewritten to be more detailed, accurate, and consistent with the ISP, updated 5/24/18. (See Attachment #24). Going forward the Program Specialist will review the individual¿s communication skills within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure the assessment has been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(3)(iii) | Individual # 1's assessment dated 10/25/17 did not specify progress in the area of personal adjustment. Individual # 2's 6/30/17 assessment did not include his/her personal adjustment skills at the facility. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the individual¿s progress in the area of personal adjustment within their assessment and ISP to ensure they are accurate, detailed and meet all licensing standards. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected, the FACT program specialist will train the FACT direct care staff on the updates and document the trainings. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure the assessment has been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(3)(iv) | Individual # 1's assessment dated 10/25/17 did not specify progress in the area of personal adjustment. Individual # 2's 6/30/17 assessment did not include his/her needs with or without assistance for the day program facility. He/She has a 50-fluid ounce fluid restriction and requires assistance to make sure he/she is following the restriction. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the individual¿s progress in the area of personal adjustment within their assessment and ISP to ensure they both are accurate and detailed enough to include items like fluid restrictions. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure the assessment has been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(4) | Individual # 1's assessment dated 10/25/17 does not identify specific supervision needs both at home and community. Assessment states No unsupervised time 24/7. Individual # 2's 6/30/17 assessment did not include his/her level of community supervision needs. According to his/her ISP she requires supervision always while out in the community. | The assessment must include the following information: The individual¿s need for supervision. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review specific supervision needs both at home and community within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure the assessment has been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(9) | Individual 1's recorded documentation of disability in 10/25/17 assessment does not include spondyliosis without myelopathy, Irritable bowel syndrome, Arthritis, Personality D/O or Mood D/O as identified in 08/28/17 physical. - Individual # 2's 6/30/17 assessment did not include his/her diagnosis and functional and medical limitations. His/Her assessment indicated diagnosis of PDD and specific autism psychological. According to his/her 2017 physical he/she is diagnosed with psychosis, mild IDD, type 2 dm-insulin dependent, hyponatremia, elevated cholesterol, hypothyroidism, edema, chronic tinea pedis, elevated triglycerides, overactive bladder, hypertension, cataracts, deafness, and glaucoma. His/Her 2018 lifetime medical history also includes a diagnosis of obesity, exotropia, incontinence, nearsightedness, PDD, profound hearing loss, and pseudo phakia. His/Her ISP also says he/she has a diagnosis of bipolar in remission | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recorded documentation of disabilities within their assessment, physicals and ISP to ensure they are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(10) | Individual # 1's lifetime medical history was not attached to 10/25/17 assessment as indicated. Individual # 2's assessment didn't include a lifetime medical history. The assessment indicated please attach a copy of the lifetime medical.' | The assessment must include the following information: A lifetime medical history. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Program specialists will now include lifetime medical histories in the body of the assessments as recommended by inspectors. (See Attachment #24). Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(11) | Individual # 1 was hospitalized for suicidal ideation on 07/10/17 at Brandywine Hospital. Psychological evaluation not contained in the record. | The assessment must include the following information: Psychological evaluations, if applicable. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Moving forward documentation used for discharging individuals will include requests for Psychological Evaluations in the case of Psychiatric Hospitalization by 8/30/18. The Program Specialist will review the Psychological Evaluation provided and include a detailed description of the findings in the assessment. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
08/30/2018
| Implemented |
| 2380.181(e)(12) | Individual # 2's assessment did not include recommendations for specific areas of training, services and programming. His/Her assessment indicated Individual # 2 loves his/her day program and his/her current level of employment is not interested in changing it. This has not changed.' | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations for specific areas of training, services and programming within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews |
06/08/2018
| Implemented |
| 2380.181(e)(13)(i) | Individual # 1's assessment dated 10/25/17 did not update progress and growth in the area of health. No documentation of Hospitalization in 07/17 for suicidal ideation. Individual # 2's 6/30/17 assessment did not include his/her current level and progress over the last 365 days in health. His/Her 2017 and 2016 assessments were verbatim. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations for progress and growth in the area of health within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies and file the correspondence in the individual¿s program book. Once the discrepancies have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(13)(ii) | Individual # 1's assessment dated 10/25/17 did not specify progress in the area of motor and communication skills. Individual # 2's 6/30/17 assessment did not include her current level and progress over the last 365 days in motor and communication skills. His/Her 2017 and 2016 assessments were verbatim. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations for specific areas of training, services and programming within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(13)(iii) | Individual # 2's 6/30/17 assessment did not include her current level and progress over the last 365 days in personal adjustment skills. His/Her 2017 and 2016 assessments were verbatim. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations involving current level and progress over the last 365 days in personal adjustment skills within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(13)(iv) | Individual # 2's 6/30/17 assessment did not include her current level and progress over the last 365 days in socialization skills. His/Her 2017 and 2016 assessments were verbatim. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations involving current level and progress over the last 365 days in socialization skills within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(13)(v) | Individual # 2's 6/30/17 assessment did not include his/her current level and progress over the last 365 days in recreation. His/Her 2017 and 2016 assessments were verbatim | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations involving current level and progress over the last 365 days in recreation within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(13)(vi) | Individual # 1's assessment dated 10/25/17 did not specify progress in the area of Community Integration. Individual # 2's 6/30/17 assessment did not include his/her current level and progress over the last 365 days in community-integration. His/Her 2017 and 2016 assessments were verbatim. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations involving current level and progress over the last 365 days in community-integration within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(e)(14) | Individual # 2's 6/30/17 assessment did not include his/her ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the recommendations involving the individual¿s ability to swim within their assessment and ISP to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.181(f) | Individual # 2's 6/30/17 assessment was not sent to any team members. The date sent' was blank and the facility did not have documentation that it was distributed. His/Her team members included family living provider and supports coordinator. | 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). | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Beginning immediately a tracking sheet for assessments and ISP Reviews will be distributed to the Program Specialist of the facility to insure assessments and ISP Reviews are sent out according to regulation deadlines. All ISP review and assessments will be signed and dated by the Program Specialist. Also, the Program Specialist will send an email correspondence to the individual¿s team members, including the SC, to confirm with the team the date that an assessment or ISP review has been sent out and this email will include a space to decline to receive future documents (where applicable). The correspondence and any replies declining documents will be filed in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individuals program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.183(4) | Individual # 2's ISP did not include her 10 minutes of unsupervised time at the day program facility or his/her 1:3 staffing ratio. His/Her ISP said she was staffed at a ratio of 1:2 to 1:6 at the facility and 1:2 to 1:3 in the community | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. A correspondence was sent to Ind. #2¿s SC to have the ISP include his/her 10 minutes of unsupervised time at the day program facility or his/her 1:3 staffing ratio, was sent to Ind. #2¿s SC, (See Attachment #25). Going forward the Program Specialist will review assessments and ISP to ensure they both are accurate and consistent with each other and all applicable regulations. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individual¿s program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.183(5) | Individual # 2 takes medications daily for diagnosis of psychosis. His/Her ISP does not include a protocol to address his/her social, emotional and environmental needs. According to his/her 2018 and 2017 lifetime medical history documents, Individual # 2 may have behaviors that include: biting, tearing clothes, destruction of property, head banging, SIB, hair pulling, physical aggression towards staff, autistic-like behaviors, hoarding and stealing food | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. A SEEP for Ind. #2 was provided by the individual¿s provider company to FACT but was found inadequate by the licensing team. Going forward the Program Specialist will examine all SEEP received from providers and, if necessary to meet regulations, develop a new Social, Emotional and Environmental Plan for each individual who is prescribed a medication to treat symptoms of a diagnosed psychiatric illness. The Program Specialist completed a new social, emotional and environmental plan for Individual #2. (See attachment #26) Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include SEEP¿s, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.183(7)(i) | Individual # 2's ISP didn't include his/her potential to advance in vocational programming | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the individual¿s potential to advance in vocational programming within their assessment and ISP to ensure they both are accurate and consistent and meet regulation standards. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individual¿s program book. Ind. #2¿s SC was contacted, and this discrepancy was corrected in the ISP. (See Attachment #27). Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include ISP, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.183(7)(iii) | Individual # 2's ISP didn't include his/her potential to advance in community integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Ind. #2¿s SC was contacted, and this discrepancy was corrected in the ISP. (See Attachment #27). Going forward the Program Specialist will review the individual¿s potential to advance in community integrated employment within their assessment and ISP to ensure they both are accurate and consistent and meet regulation standards. During this review, if any discrepancies or omissions are found the Program Specialist will send a correspondence to the individuals team members including the SC to correct the discrepancies or omissions and file the correspondence in the individual¿s program book. Once the discrepancies or omissions have been corrected; training on the updates will be arranged by Program Specialist and the updates will be reviewed quarterly thereafter and filed in the individual¿s program book. Ind. #2¿s SC was contacted, and this discrepancy was corrected in the ISP. (See Attachment #27). Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include ISP, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.184(a) | Individual # 1's ISP signature sheet is not contained in the record. Unable to ascertain attendance and participation by team members. | 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). | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Moving forward the Program Specialist will secure an ISP signature sheet and ensure it placed in the record of the individuals program book to record the attendance and participation by team members. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include ISP signature sheet, on a quarterly basis to assure all documents have been obtained so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.185(a) | Individual # 1's ISP outcome of selling jewelry was not started by 07/01/17. | The ISP shall be implemented by the ISP's start date. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the FACT Program Specialist will implement the individual¿s ISP's on the start date and no later. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include ISP, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.185(b) | Individual # 2's ISP indicates he/she has a 50-fluid ounce daily restriction. The facility is not tracking his/her fluid intake. The facility writes daily notes that state Individual # 2 did/didn't follow his/her recommended diet.' Staff do not track his/her behaviors daily. His/Her ISP has SEEN plan to discuss tracking his/her behaviors due to his/her diagnosis of psychosis. His/Her ISP indicates she should eat a snack in the afternoon before leaving day program to keep his/her blood sugar stable. There is no documentation that day program is providing his/her with a snack prior to his/her departure from day program. His/Her ISP says caregivers will be trained in monitoring of medication side effects as part of their agency medication administration training. Copies of all Individual # 2's medication side effects sheets will be kept at both the day program and at home. Caregivers will report any possible side effects to the lifesharing program specialist or on call system. Individual # 2's doctor will be called for review of the concerns and recommendation for treatment if warranted.' The day program facility did not have a list of medication and side effect for the staff. ISP says all staff are trained in Individual # 2's communication assessment report and recommendations conducted by ODP prior to working with Individual # 2. The report was completed on 8/1/16 and staff were not trained until 8/22/17 through 3/26/18. | The ISP shall be implemented as written. | Direct care staff were trained by FACT¿s Program Specialist on individual #2¿s 50 fluid oz restriction and have signed and dated documentation of having received training on tracking fluids, (See Attachment #6). Direct care staff have been trained by the FACT Program Specialist on the ISP plan of Ind. #2, updated 5/24/18, and have signed and dated the documentation, see attached documentation, (See Attachment #7). Ind. #2¿s SEEN plan submitted by his/her provider and found inadequate by inspectors has been replaced by one created by the Program Specialist to better meet regulations. (See Attachment #26). Ind. #2¿s SC has been contacted and the administration of the afternoon snack has been clarified in the ISP, updated 5/24/18, to reflect that Ind. #2 self-administers her snack provided from home. Direct care staff have been trained on the most current medication list for Individual #2 and have been trained on information pertaining to the medications being taken, see attached documentation. (See Attachment #8). Going forward all new direct care staff will be trained by Program specialist on individual #2¿s 50 fluid oz restriction and have signed and dated documentation of fluid intake on fluid intake forms. Going forward the facility will receive complete medication lists from providers and request updates for changing medications, along with a list of medications and side effects for all consumers by 8/30/18. Ind. #2¿s SC has been contacted about the discrepancy in the dates of the Communication Assessment and provided documentation of when SC received the finalized CAR Report and then forwarded via email to Francis Washington, Brian Havlik, and Bendu Outland on 7/3/17. Report was discussed at the ISP meeting on 8/8/17. FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review practices, needs, and, supports outlined within the ISP to ensure direct care staff are adequately trained and that they are accurately implemented and documented. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include ISP, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
08/30/2018
| Implemented |
| 2380.186(a) | Individual # 1's ISP reviews did not include reviews of behavior plan, selling jewelry outcome, supervision plan or community integration. Per PS, the direct support staff create the individual's ISP reviews. None of the ISP reviews are dated for completion so unable to determine if completed on a quarterly time frame. Individual # 2 had a quarterly completed for the review period from 11/20/16-2/20/17 and not another review completed until the one completed that covered the review period 6/20/17-8/20/17. | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Ind. # 2¿s missing quarterly will be completed by 8/30/18. Going forward the Program Specialist will review the updates of behavior plans, outcomes, supervision and community integration within the ISP and ISP Review to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will correct the discrepancies or omissions before sending the document out to the individuals team members, including the SC. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include the ISP and ISP reviews, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
08/30/2018
| Implemented |
| 2380.186(b) | Individual # 1's ISP reviews do not contain dates. The program specialist and individual # 2 did not date any ISP reviews. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. All ISP review and assessments will be signed and dated by the Program Specialist. Also, the Program Specialist will send an email correspondence to the individual¿s team members, including the SC, to confirm with the team the date that an assessment or ISP review has been sent out and this email will include a space to decline to receive future documents (where applicable). The correspondence and any replies declining documents will be filed in the individual¿s program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include the ISP and assessments, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.186(c)(2) | Individual # 2's ISP reviews do not review her dietary restriction, his/her receiving a snack at the end of the day, his/her unsupervised time, behaviors, seen plan, communication plan/support | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the dietary restriction, individual dietary supports unsupervised time, behaviors, seen plans, communication plans/supports within the ISP and ISP Review to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will correct the discrepancies or omissions before sending the document out to the individuals team members, including the SC. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include the ISP and ISP reviews, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.186(c)(2) | Individual # 1's monthly reviews did not include updates of behavior plan (body charting daily due to self injurious behaviors), or outcome of selling jewelry. Individual # 2's ISP reviews do not review his/her dietary restriction, his/ her receiving a snack at the end of the day,his/ her unsupervised time, behaviors, seen plan, communication plan/support | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward the Program Specialist will review the updates of behavior plans or outcomes within the ISP and ISP Review to ensure they both are accurate and detailed. During this review, if any discrepancies or omissions are found the Program Specialist will correct the discrepancies or omissions before sending the document out to the individuals team members, including the SC. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include the ISP and ISP reviews, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.186(d) | No documentation in Individual # 1's record that ISP reviews were sent to all team members. - No documentation that ISP reviews were sent to Individual # 2's team (family living provider, individual and SC) | 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. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. Going forward, all ISP review and assessments will be signed and dated by the Program Specialist. Also, the Program Specialist will send an email correspondence to the individual¿s team members, including the SC, to confirm with the team the date that an assessment or ISP review has been sent out and this email will include a space to decline to receive future documents (where applicable). The correspondence and any replies declining documents will be filed in the individual¿s program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include the ISP, assessments and ISP reviews, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |
| 2380.186(e) | No documentation in Individual # 1's record that the option to decline ISP reviews was offered to team members. no documentation that the program specialist offered any of individual # 2's team members the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | FACT program¿s Program Specialist has reviewed the regulations 55 PA Code § 2380 and has received training on the regulations and his role as specified in § 2380.33 by his Director of Services. Signed and dated documentation of PS training will be kept on file, (See Attachment #2). Any future Program Specialists will be trained on 55 PA Code Chapter § 2380.33 and explained their duties by their Director of Services prior to beginning their duties and this training will be signed and dated and documented. All ISP review and assessments will be signed and dated by the Program Specialist. Also, the Program Specialist will send an email correspondence to the individual¿s team members, including the SC, to confirm with the team the date that an assessment or ISP review has been sent out and this email will include a space to decline to receive future documents (where applicable). The correspondence and any replies declining documents will be filed in the individual¿s program book. Kelsch¿s Director of Services will examine a random selection of 2 consumer Books, which would include the ISP, assessments and ISP reviews, on a quarterly basis to assure all documents have been completed so as to meet all licensing standards. Kelsch¿s Director of Services will maintain a record documenting the reviews. |
06/08/2018
| Implemented |