| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 12/15/15, a $500 check was written to the Ganister Station day program from Individual #1's account. The memo field on the check reads ¿donation¿ and the check is signed by Staff #1. Staff #1 stated that this donation was not discussed with or approved by Individual #1. This transfer of funds constitutes financial exploitation. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The Administrator is payee for individual #1 and was responsible for assuring that Individual #1 did not exceed state asset standards. The representative from the PA Blair County Assistance Office stated that Donations to 501(c) organizations was an allowable spenddown to assure he does not retain extra capital.. After dicussion with the individual, the individuals parents and with the Assistance Board representative a decision was made to donate money to the Day Program he attends. The family felt that Individual #1 would benifit of increased day program opportunities through the donation since he spends 40 + hours per week there. The Administrator was shocked to learn that by licensing standards this would be considerd financial exploitation. The money was immediately returned to Individual #1 (ATTACHMENT CC-8.) The Administrator is committed to assuring transparency and sound fiscal management for individual's funds and has been trained in the agency policy and regulations. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.22(d)(2) | On 1/11/16 a check was written ¿for cash¿ from Individual #1's account in the amount of $40. Only $30 cash from that check was deposited into his petty cash ledger. | (2) Disbursements made to or for the individual.
| See paper copy. |
11/23/2016
| Implemented |
| 6400.22(e)(3) | The agency did not have a receipt for any of the $543.67 room and board payments from Individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Immediate Correction: Individual #1 was provided with a reciept identifing the Room and Board Payment dated 9/14/2016. ATTACHMENT CC-7A, CC-7B. Prevention: The Accounts manager was unable to complete all of the monitoring duties and Mattern House created an Accounting Assistanct possition who is responsible to assure that individuals receive Monthly statements which include a comprehensive statement. She has been trained to meet licensing standards. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.31(b) | Individual #1 did not date the signed statement that his rights were reviewed with him. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Immediate Correction: Cannot fix missed date. Prevention / Correction: The Non Didcrimination / Health Care Consent form has been redesigned to include the date on the same line as the signature. We have adopted the new form and are actively using it for new admissions. ATTACHMENT: CC- 5a The Administrative Assistant and Program Specialist who are responsible for dissemination of this form have been trained in the use of the form. ATTACHMENT T-1A, T-1B. |
10/15/2016
| Implemented |
| 6400.68(c) | The home had a coliform water test completed on 9/10/15 and not again until 1/4/16, outside the 3 month time frame. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | The 3 month Coliform test is an important health measure to assure the consumpsion of safe water. Maintenance was unable to explain why tests had been completed every three months as per the regulation but December's test was completed in January, then resumed the 3 month schedule as per the regulation. Prevention: The Administrative Assistance has added Water tests reminders to her Outlook and developed a new process to assure it is completed along with water temperature tests. ( ATTACHMENT: CC-4) The Maintenance staff is responsible for timely completion of the test and have been trained in their responsibiltiy to meet the regularions. ATTACHMENT: T-1A, T-1B. |
12/13/2016
| Implemented |
| 6400.74 | The back patio steps and front porch steps were not equipped with non-skid surfaces. | Interior stairs and outside steps shall have a nonskid surface.
| The 3 month Coliform test is an important health measure to assure the consumpsion of safe water. Maintenance was unable to explain why tests had been completed every three months as per the regulation but December's test was completed in January, then resumed the 3 month schedule as per the regulation. Prevention: The Administrative Assistance has added Water tests reminders to her Outlook and developed a new process to assure it is completed along with water temperature tests. ( ATTACHMENT: RR-13) The Maintenance staff is responsible for timely completion of the test and have been trained in their responsibiltiy to meet the regularions. ATTACHMENT: T-1A, T-1B. |
12/13/2016
| Implemented |
| 6400.211(b)(3) | Individual #1's record did not include the name, address, and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Corrective Action: Individual #1's Emergency Record has been updated to identify the Administrator as the person able to give consent. ATTACHMENT: CC-1. Issue: Prior recommendations for this regulatory requirement directed us to list the person themself if they did not have a legal guardian. We now have a new understanding of the use / need for this information and going forward will identify the Administrator here. Staff have been trained with this new information. The Administrator has been educated in the content of emergency medical treatment as per ODP Bulletin 6000-11-01 . T-1A, T-1B |
11/23/2016
| Implemented |