| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
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SIN-00218493
|
Renewal
|
02/27/2023
|
Compliant - Finalized
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|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.58(a) | Wall paint by the toilet in the single-stall front entrance bathroom, is peeling. A ceiling tile is broken in the same bathroom.
There is peeling/scraped off paint behind the grab bar by the toilet in the other single-stall bathroom by the front entrance. | Floors, walls, ceilings and other surfaces shall be in good repair. | A local painter was contracted to remove all peeling paint & repair/replace any ceiling tiles in the facility that needs attention. Individuals were involved in the selection of new & updated colors for the entire interior area of the facility. |
03/20/2023
| Implemented |
| 2380.174(b) | The Individual Support Plan (ISP) kept at the facility for Individual #1 was last updated on 10/18/22. However, at the time of the 2/27/23 inspection, the individual's ISP has been updated 3 more times, most recently on 1/17/23. The most recent update to the plan was not kept at the facility in the individual's record. | The most current copies of record information required in § 2380.173(2)(11) shall be kept at the facility. | The most recent ISP dated 3/6/2023 for Individual #1 was printed and staff are being trained on it. Staff will go through all files and print off all the updated ISP's per person and train staff on them if there are any changes and then put a copy in their files by 3/31/23. |
03/14/2023
| Implemented |
| 2380.21(u) | Individual #1 started attending the program on 9/7/22. Upon admission, they were not informed of their rights defined under 2380.21(b)-(g), (j), (l), and (r)-(t). Additionally, they were not informed of their rights defined in 2380.21(h) until 10/19/22, after admission to the facility.
Individual #2 was not informed of their rights defined in 2380.21(a)-(t) annually. The rights reviewed with the individual on 7/18/22, 2/11/22, and 2/12/21 did not include a review of their rights defined under 2380.21(b)-(g), (j), (l), and (r)-(t). Additionally, they were not informed of their rights defined in 2380.21(h) until 10/20/22. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | The individual rights were updated to reflect all regulations outlined on 2380.21. All individuals will have their right reviewed with them including Individual #1 and Individual #2. |
03/20/2023
| Implemented |
| 2380.125(f) | Individual #1's most recent Individual Support Plan (ISP) does not include a complete plan of support to address the individual's social, environment, and emotional needs relating to the symptoms of their psychiatric illness. Their ISP currently states the individual will not become physically aggressive when upset. However, the individual did become physically aggressive when upset at the program. The individual's ISP and other plans did not address how to support the individual through physical aggression.
Additionally, the individual's ISP states they do not have a behavior support plan. The agency produced a social, emotional, and environmental needs plan (SEEP) for Individual #1 that states if they have tracked behaviors, they will be reported to the team for further assistance. This portion of the SEEP is also not included in the individual's ISP. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Individual #1's SEEP plan was updated to reflect showing physical aggression and what support is needed while at the program. Staff were trained on the new plan of support. The Supports Coordinator was emailed the plan and asked to add it to their ISP. |
03/06/2023
| Implemented |
|
|
|
SIN-00201222
|
Renewal
|
03/08/2022
|
Compliant - Finalized
|
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(a) | Staff person #2 date of hire is 9/20/21. Her physical was not completed prior to her employment. The physical was completed 9/24/21 and TB completed 9/27/21. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | All new hires will have their physical & TB test read prior to their first day of employment. |
03/10/2022
| Implemented |
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|
|
SIN-00180650
|
Renewal
|
12/16/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(d) | The January 7, 2020 fire drill does not indicate how long it took to evacuate during the drill. This section is left blank on the form. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | This regulation is important for the safety of the individuals we support. It provides written documentation of the timeframe that we are safely able to get everyone out of the building to a designated meeting place. By having the monthly drills, it also shows any potential problems that we may need to address as well as the individuals learning what to do incase of a real emergency.
The fire drill for 1/7/2020 did not indicate how long it took to evacuate during the drill. That section was left blank.
It happened due to an oversight on the part of the Program Specialists.
We will redo another fire drill ensuring the section indicating how long it took to evacuate during the drill is not left blank on the form.
See attachment #1.
The person in charge of documentation will be the 3rd set of eyes to insure all sections of the fire drill form was filled out completely. |
12/22/2020
| Implemented |
| 2380.21(u) | Both Individual #1 and Individual #2 were informed of their rights, except for the right to refuse to participate in activities and services, 2380.21m. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | This regulation is important because it allows the individual to have the freedom to not only choose what they would like to do and when, but also refuse any activities or services that they do not want.
The individual rights, choice & responsibilities form did not have that they have the right to refuse to participate in activities and services.
This happened due to thinking that the below statements covered that area.
The right to actively participate in any program planning and to have a flexible schedule that is individualized and based on my needs and desires.
The right to change my schedule and take breaks if needed.
The statement The right to refuse to participate in activities and services has been added to the individual rights, choice & responsibilities form and were gone over again with both individuals.
See Attachments #2 & #3.
The individual rights, choice & responsibilities form has been updated and will be updated in every individuals file. It will be updated annually thereafter. |
01/31/2021
| Implemented |
|
|
|
SIN-00164947
|
Renewal
|
10/22/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(1) | LMH physical- Individual #1's 1/22/19 physical examination did not include his/her medical history around his/her self-injurious behaviors, pulling out the hairs on the head, legs and eyelashes, or eating of inedible objects like paper, depends, etc. Per the agency program specialist, Individual #1's currently ingests or attempts to ingest inedible objects. This was not mentioned in the document. | The physical examination shall include: A review of previous medical history. | Why is the regulation important? This regulation is important because staff need to review previous medical history on the physical examination form in order to be properly trained and provide appropriate care to those individuals they support.
What happened? Individual #1's 1/22/19 physical examination did not include his/her medical history around his/her self-injurious behaviors, pulling out the hairs on the head, legs, and eyelashes, or eating of inedible objects like paper, depends, etc. Per agency program specialist, Individual #1's currently ingests or attempts to ingest inedible objects. This was not mentioned in the document.
Why did it happen? The doctor failed to place self-injurious behaviors and eating of inedible objects on the previous medical history section of the 1/22/19 physical. The residential provider along with the agency day program specialist failed to make note of self-injurious behaviors or eating of inedible objects under the review of previous medical history section of the 1/22/19 physical.
What do we do right now? Correspondence was made on 12/5/19 to Individual #1's residential provider LPN requesting that self-injurious behaviors and eating of inedible objects be added to Individual #1's 1/22/19 physical. (Attachment #5a)
How do we prevent this from happening again? Correspondence by email (Attachment #6a) was sent to the residential LPN who oversees coordination of medical services on November 20, 2019 to inquire if there has ever been any diagnosis of PICA or whether it has ever been discussed with the PCP. Correspondence by email was also sent out to team members on November 26, 2019 (Attachment #6b) to all team members requesting that a team meeting be held to discuss supervision and the concerns that were brought up at licensing inspection. A team meeting is scheduled for December 10, 2019 at 9:00am with Individual #1 team to further discuss self-injurious behaviors and eating of inedible objects. |
12/10/2019
| Implemented |
| 2380.111(c)(11) | Individual #1's 1/22/19 physical examination did not include any dietary information specific to the size that his/her food should be cut into or that he/she is a choking risk due to shoveling food in his/her mouth too fast. The physical form stated, "diabetic, low purine (gout)diet recommended by PCP." The agency program specialist added "cut food into 1x1 inch (quarter size) pieces" on 10/31/19. The individual #1's ISP stated at least 3 times, "recommended diet, he/she follows a low purine, diabetic diet." The ISP says he/she has a meal protocol in place at day program and his/her food is to be cut into 1.5 inch bites. The individual's 7/26/19 meal protocol for day program says for the individual to follow "diabetic- low purine (gout) diet. PCP recommends quarter size (1 inch x 1 inch) pieces of food." The multiple documents in the individual's record regarding his/her dietary needs, do not match. The agency still had individual #1's dietary information hanging in a cabinet in the kitchen which read that his/her food should be cut into 1.5 inch pieces. Dietary recommendations to cut foot up into a specific size were not included on the 1/22/19 physical examination by the individual's physician. Information was added by day program staff 10 months later. | The physical examination shall include: Special instructions for an individual's diet. | Why is the regulation important? This regulation is important because we must have special instructions for individual's diet listed on the current physical so that staff are properly informed and trained on special instructions/protocols for each individual's dietary needs.
What happened? Diet-Physical-Individual #1¿s 1/22/19 physical examination did not include any dietary information specific to the size that his/her food should be cut into or that he/she is a choking risk due to shoveling food in his/her mouth too fast. The physical form stated, "diabetic, low purine (gout) diet recommended by PCP."The agency program specialist added "cut food into 1x1 inch (quarter size) pieces¿ on 10/31/19. The individual #1's ISP stated at least 3 times, "recommended diet, he/she follows a low purine, diabetic diet." The ISP says he/she has a meal protocol in place at day program and his/her food is to be cut into 1.5 inch bites. The individuals 7/26/19 meal protocol for day program says for the individual to follow "diabetic-low purine (gout) diet. PCP recommends quarter size (1 inch x 1 inch) pieces of food.¿ The multiple documents in the individual's record regarding his/her dietary needs, do not match. The agency still had individual #1's dietary information hanging in a cabinet in the kitchen which read that his/her food should be cut into 1.5 inch pieces. Dietary recommendations to cut food up into a specific size were not included on the 1/22/19 physical examination by the individual's physician. Information was added by day program staff 10 months later.
Why did it happen? The agency program specialist failed to update the physical and corresponding documents in a timely fashion and didn't correct discrepancies in the record with regards to diet recommendations.
What do we do right now? The agency program specialist contacted individual #1's residential provider via email (Attachment #5a, #5b, and #5c), requesting for information to be added to the physical regarding special instructions for Individual #1's meal protocol (Attachment #5d.). A medical consult form dated July 25, 2019 from PCP gives instructions to change meal protocol to bite size pieces of quarter size. (Attachment #5f) has been updated to reflect (1 inch x 1 inch) for bite size pieces and this was replaced in the kitchen area.
How do we prevent this from happening again? The agency program specialist corresponded with Individual #1 residential provider requesting that information be added to 1/22/19 physical (Attachment #5a, #5b, #5c,) that reflects doctor's recommendation for Individual #1's meal protocol (Attachment #5d). The agency program specialist also corresponded with Individual #1's Supports Coordinator on 10/16/19 (Attachment #5g) and completed a track change to the ISP Meals/Eating section (Attachment 5h) and made an assessment addendum on 10/31/19 stating the new meal protocol. (Attachment #5i) |
12/10/2019
| Implemented |
| 2380.111(c)(11) | The 1/17/19 annual physical is documented for diet is 1500 calorie per day may increase to 1800 calories, high protein. The choking risk screening completed 1/7/19 says current diet 1500-1800 cal day, 80 gms protein and protein shake daily and is NOT a choking risk. The 5/10/19 assessment is documented in the personal needs with/out assistance that Individual #2 requires prompts to chew or swallow, on a regular diet but he does not feed himself, but his food should be cut up in small bite size pieces/chopped or ground in a food processor. The 7/10/19 ISP is documented in the Meals/Eating section that food should be cut into small bite size pieces/chopped or ground in food processor. Individual #2 has a fluid intake protocol to ensure he has 64-80 oz of fluid daily to keep his kidneys flush. The information regarding Individual #2's food prep and fluid intake needs to be added to the physical and be consistent in the record. | The physical examination shall include: Special instructions for an individual's diet. | Why is the regulation important? This regulation is important because we must have special instructions for individual's diet listed on the current physical so that staff are properly informed and trained on special instructions/protocols for each individual's dietary needs.
What happened? Physical-Special Dietary Instructions-The 1/17/19 annual physical is documented for diet is 1500 calorie per day may increase to 1800 calories, high protein. The choking risk screening completed 1/7/19 says current diet 1500-1800 cal day, 80 gms protein and protein shake daily and is NOT a choking risk. The 5/10/19 assessment is documented in the personal needs with/out assistance that Individual #2 requires prompts to chew or swallow, on a regular diet but he does not feed himself, but his food should be cut up in small bite size pieces/chopped or ground in a food processor. The 7/10/19 ISP is documented in the Meals/Eating section that food should be cut into small bite size pieces/chopped or ground in the food processor. Individual #2 has a fluid intake protocol to ensure he has 64-80 oz of fluid daily to keep his kidneys flush. The information regarding Individual #2's food prep and fluid intake needs to be added to the physical and be consistent in the record.
Why did it happen? The agency program specialist didn't have consistent information regarding Individual #2's Meal Protocol and Fluid Intake Protocol listed in the 5/10/19 or 7/10/19 ISP based off information on Individual #2's 1/17/19 physical.
What do we do right now? The agency program specialist completed a new CCC Meal Protocol (Attachment #4a.) based off Supportive Concepts For Families diet protocol that was recommended by Individual #2's Dietician and PCP (Attachment #4b.) The agency program specialist also completed a new Fluid Protocol (Attachment #4c.) based off of Supportive Concepts For Families Fluid Intake Protocol (Attachment #4d.)
How do we prevent this from happening again? The agency program specialist completed a new CCC Meal Protocol (Attachment #4a.) based off Supportive Concepts For Families diet protocol that was recommended by Individual #2's Dietician and PCP (Attachment #4b.) The agency program specialist also completed a new Fluid Protocol (Attachment #4c.) based off of Fluid Intake Protocol (Attachment #4d.) An email was also sent to the residential program specialist and nurse regarding a pass along book being used to track his fluid intake. (Attachment #4e.) The agency program specialist also completed an assessment addendum for Individual #2¿s 5/10/19 assessment to include updated, consistent information regarding Individual #2¿s Meal Protocol and Fluid Protocol (Attachment #3a.) The agency program specialist also sent correspondence through an email to Individual #2's Supports Coordinator to add information to Individual #2 ISP based off the assessment addendum page. (Attachment #3b) |
12/10/2019
| Implemented |
| 2380.181(e)(7) | - Knowledge of heat source- Individual #2's 5/10/19 assessment does not address the ability to move away from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Why is the regulation important? This regulation is important because the assessment needs to list the individuals understanding of heat sources so that we are able to protect them from these heat sources if they have no understanding of the dangers associated with heat sources.
What happened? Knowledge of heat source-Individual #2's 5/10/19 assessment does not address the ability to move away from heat sources.
Why did it happen? The agency program specialist didn't specifically note Individual #2's understanding of heat sources or ability to sense and move away from heat sources on the 5/10/19 assessment.
What do we do right now? The agency program specialist completed an assessment addendum to the 5/10/19 assessment to include Individual #2's understanding of heat sources and ability to sense and move away from heat sources. (Attachment #3a.)
How do we prevent this from happening again? The agency program specialist updated Individual #2's 5/10/19 assessment by completing an addendum to include Individual #2's understanding of heat sources and his ability to sense and move away from heat sources. (Attachment #3a.). The agency program specialist also corresponded with the Supports Coordinator via email to make additions to the Plan of Care based off information on the assessment addendum. (Attachment #3b.) |
12/10/2019
| Implemented |
| 2380.181(e)(10) | Individual #1's current 6/20/19 assessment did not include his/her medical history around his/her self-injurious behaviors, pulling out the hairs on his/her head, legs and eyelashes, or his/her eating of inedible objects like paper, depends, etc. Per the agency program specialist, Individual #1'scurrently ingests or attempts to ingest inedible objects and also has done this for years. The extent of his/her self-injurious behaviors, items that he/she ingests or attempts to ingest and how often he/she pulls the hairs out of his/her body are not mentioned. | The assessment must include the following information: A lifetime medical history. | Why is the regulation important? This regulation is important because we must keep up to date and descriptive medical histories that are consistent with the Plan of Care and physical that gives accurate information about the individual's current and past medical history.
What happened? Individual #1¿s current 6/20/19 assessment didn't include his/her medical history around his/her self-injurious behaviors, pulling out the hairs on his/her head, legs, and eyelashes, or his/her eating of inedible objects like paper, depends, etc. Per the agency program specialist, Individual #1 currently ingests or attempts to ingest inedible objects and also has done this for years. The extent of his/her self-injurious behaviors, items that he/she ingest and how often he/she pulls the hairs out of his/her body are not mentioned.
Why did it happen? The agency program specialist didn't include detailed information about Individual #1's self-injurious behaviors or eating of inedible objects in her assessment.
What do we do right now? The agency program specialist made changes to the 6/20/19 current assessment by completing an addendum to include detailed information about Individual #1's self-injurious behaviors and eating of inedible objects. (Attachment 2a.)
How do we prevent this from happening again? The agency program specialist made changes to the 6/20/19 assessment by completing an addendum to include updated, detailed information regarding Individual #1's self-injurious behaviors and eating of inedible objects. (Attachment 2a.). The agency program specialist also sent the assessment addendum page to the Supports Coordinator so that Individual #1's Plan of Care can be updated to include new additions from the assessment addendum. (Attachment 2b.) |
12/10/2019
| Implemented |
| 2380.37(a) | Training records kept- Staff person #1's training record does not contain who the trainer was for 28 listed topics such as fall protocols for Individuals, seizures, choking, GERD, repositioning, BSP's & diet protocols | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | Why is the regulation important? Accurate and up to date training records are important because they reflect staff current level of experience with particular topics that are related to the Plan of Care, Health and Safety, and overall continuity of care for individuals served.
What happened? Staff person #1's training record didn¿t contain who the trainer was for 28 listed topic such as fall protocols for individuals, seizures, choking, GERD, repositioning, BSP's & diet protocols.
Why did it happen? Staff #1 was handwriting her entries onto the training log and she forgot to enter the name of the trainer for 28 listed training topics.
What do we do right now? Staff person #1 is now documenting her training records on an electronic form instead of handwriting her entries.
How do we prevent this from happening again? All staff are now required to keep an up to date training log on the computer and make electronic entries onto the new training form (Attachment 1a.) |
12/10/2019
| Implemented |
|
|
|
SIN-00146058
|
Renewal
|
12/20/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.21(b)(4) | The entrances and exits of the facility have been installed with video recording devices. There is no documentation to indicate that the individuals and/or their legal guardians have been informed of the video recording taking place or consenting to their use. | The facility shall develop and implement civil rights policies and procedures. Civil rights policies and procedures shall include the following: Informing individuals on their right to register civil rights complaints. | Individuals and their legal guardians should be notified that they are being video recorded and given the opportunity to consent.
The entrances and exits of the facility have been installed with video recording devices. There is no documentation to indicate that the individuals and/or their legal guardians have been informed of the video recording taking place or consenting to their use.
CCC was unaware that video cameras that are used for security purposes infringed on the civil rights of the individuals being served. The video cameras are only being used to monitor activity around the perimeter of the property due to criminal mischief and vandalism.
We have updated our Compass Community Connections Civil Rights Policy (See Attachment #14a) to now include a statement that informs individuals being served and employees that there is video recording on the exterior of facilities and also interior hallways for the purpose of safety and security.
Individuals and legal guardians were given an updated copy of the Compass Community Connections Civil Rights Policy informing them of the use of video surveillance for security purpose. Video Surveillance signs were purchased and will be placed at all entrance and exits of the property, informing people that video surveillance is taking place. Please see (Attachment #14b) of the sign that was purchased. |
01/17/2019
| Implemented |
| 2380.36(d) | Staff #1's date of hire was 10/8/18 and he didn't have training on services for people with disabilities and program planning and implementation until 11/12/18; over 30 days after his date of hire. | Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | This regulation is important because all staff working with individuals with disabilities should be trained on services for people with disabilities and program planning and implementation.
Staff #1's date of hire was 10/8/18 and he didn't have training on services for people with disabilities and program planning and implementation until 11/12/18; over 30 days after his date of hire.
The Program Specialist was late on training Staff #1¿s on services for people with disabilities and program planning and implementation and it exceeded the 30 days from Staff #1¿s date of hire.
We updated our Orientation Checklist to include specific timeframes for new staff orientation.
We will start to implement the new Orientation Checklist with new hire staff to allow us to better track our trainings and assure that we are staying in compliance with regulations. Please see (Attachment 13a) |
01/16/2019
| Implemented |
| 2380.53(a) | Individual's at the facility are assessed to not be safe around poisonous materials. Dishwashing liquid that contained a label to contact poison control center if ingested was found unlocked and accessible under the kitchen sink in the same area where the individual's eat lunch. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | This regulation is important because individuals who don¿t have knowledge of poisonous materials could ingest poisonous materials if they are kept unlocked jeopardizing their health and safety.
Individuals at the facility are assessed to not be safe around poisonous materials. Dishwashing liquid that contained a label to contact poison control center if ingested was found unlocked and accessible under the kitchen sink in the same area where the individual's eat lunch.
Staff members didn¿t lock up the dishwashing liquid that was underneath the sink.
The dishwashing liquid was locked up and made inaccessible to individuals who don¿t have knowledge of poisonous materials.
A Safety Sweep Checklist was created to include date, time, poison locked, sharps locked, and then staff initials. This form will be used by staff daily to assure that poisons and sharps are kept locked and inaccessible to individuals who don¿t have knowledge of poisonous materials. Please see (Attachment 12a) |
01/07/2019
| Implemented |
| 2380.89(g) | Individual #2 did not evacuate the building during the 10/20/17 fire drill held at the building and another fire drill was not held during the month of October 2017 where Individual #2 evacuated the building. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | We must make sure that all individuals are able to evacuate the building in order to maintain their health and safety. Fire Drills allow us to assess individual¿s needs during these drills so that we can provide the best possible support during an actual fire.
Individual #2 did not evacuate the building during the 10/20/17 fire drill held at the building and another fire drill was not held during the month of October 2017 where Individual #2 evacuated the building.
Staff didn¿t reschedule another fire drill in October 2017 to assure that Individual #2 was able to evacuate to a designated meeting place outside the building or within the fire safe area during each drill as the regulations states.
The CCC Monthly Fire Drill Record was updated to inform the Program Specialist to have a repeat drill if any individual doesn¿t evacuate to a designated meeting place.
Program Specialist will begin using the updated CCC Monthly Fire Drill Record that now informs them to have a repeat fire drill if any individuals doesn¿t evacuate to the designated meeting place. (See Attachment #11a) |
01/07/2019
| Implemented |
| 2380.111(a) | Individual #1's date of admission is 11/27/17 and did not have a physical exam completed until 12/7/17, after the individual's date of admission. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This regulation is important because the provider agency needs to be aware of the current and past health information in order to provide the best quality of care to meet the health and safety needs of the individuals that are served.
Individual #1's date of admission is 11/27/17 and did not have a physical exam completed until 12/7/17, after the individual's date of admission.
The program specialist didn¿t secure a physical examination prior to Individual #1¿s date of admission. She didn¿t have a tracking system that she could refer to make sure that she had the physical within 12 months prior to admission.
Staff were trained on the new CCC Annual Due Date Checklist to include physicals upon admission and then annually thereafter. (See Attachment 3a)
The CCC Annual Due Date Checklist was updated to include a physical section that states physicals must be completed within 12 months prior to admission and annually thereafter. Program Specialist are responsible for adding new admission¿s to the annual checklist and assure that information is up to date within ODP regulations. (Please see Attachment 3b) |
01/07/2019
| Implemented |
| 2380.113(c)(2) | Staff #1's date of hire is 10/8/18 and he did not receive a Tuberculin skin test with negative results completed until 10/10/18, two days after his date of hire. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | This regulation is important because 2380.113 (a) states that prior to employment means prior to date of hire/first date person is paid they must have a physical examination. Compass Community Connection has their TB testing on their physical and this must be completed prior to the staff member physically working with the individuals to assure that staff member is free from communicable diseases.
Staff #1's date of hire is 10/8/18 and he did not receive a Tuberculin skin test with negative results completed until 10/10/18, two days after his date of hire.
Staff #1 received his TB and physical on his first date of hire and then had physical contact with individuals in the program before the TB shot was read and confirmed negative.
We changed our new hire practices to now include a reminder to the HR Department that physical and TB must be done prior to the date of hire.
HR will now be using the updated new hire checklist form that alerts HR Department that physical and TB must be done prior to date of hire/first day of work. Please see (Attachment #9a) |
01/08/2019
| Implemented |
| 2380.128(a) | Staff #2 has been passing medications for a few years at the facility without being certified to pass medications by a certified medication administration trainer. Staff #3, who has not been a medication trainer since her medication trainers certificate expired on 6/30/15, signed as the medication trainer for Staff #2's current medication practicum on 4/14/18. | A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | This regulation is important because staff have to understand the proper ways to administer medication so that they can appropriately provide care for the individuals that we serve. Completing and passing the Department's Medications Administration Course demonstrates that staff have the knowledge of administering medication properly.
Staff #2 has been passing medications for a few years at the facility without being certified to pass medications by a certified medication administration trainer. Staff #3, who has not been a medication trainer since her medication trainers certificate expired on 6/30/15, signed as the medication trainer for Staff #2's current medication practicum on 4/14/18.
Staff #2 assumed that since she taught the Department¿s Medication Administration Course she was authorized to pass medication. She wasn¿t aware that she had to be trained by another agency staff in Medication Administration since she was a trainer herself.
Staff #2 will not pass medication until she has successfully completed the Departments Medication Administration Course.
Staff #2 will be trained by Staff #3 once she successfully takes and passes ODP certified medication administration trainer course. Staff #2 will also be taking the ODP Certified Medication Administration Trainer Course so that she can train Staff #3. They will both be signing up for the 5/23/19 Face to Face Certified Medication Administration Training being held in State College, PA. |
05/23/2019
| Implemented |
| 2380.128(c) | Staff #2 has been passing medications for a few years at the facility without being certified to pass medications by a certified medication administration trainer. Staff #3, who has not been a medication trainer since her medication trainers certificate expired on 6/30/15, signed as the medication trainer for Staff #2's current medication practicum on 4/14/18. | Medications administration training of staff persons shall be conducted by an instructor who has completed and passed the Medications Administration Course for trainers and is certified by the Department to train staff persons. | This regulation is important because staff have to understand the proper ways to administer medication so that they can appropriately provide care for the individuals that we serve. Completing and passing the Department's Medications Administration Course demonstrates that staff have the knowledge of administering medication properly.
Staff #2 has been passing medications for a few years at the facility without being certified to pass medications by a certified medication administration trainer. Staff #3, who has not been a medication trainer since her medication trainers certificate expired on 6/30/15, signed as the medication trainer for Staff #2's current medication practicum on 4/14/18.
Staff #3 assumed that since she was observed by Staff #2, who is a certified medication administration trainer, and held a held a certificate from 6/30/15 thought that she was certified to sign off as a practicum observer for Staff #2.
Staff #2 will not administer medications until she is trained by a certified medication administration trainer and Staff #3 will not assume the role of medication trainer until she gets certified through ODP Medication Administration Training.
Both staff #2 and Staff #3 will be scheduled for the next available ODP Certified Medication Administration Trainer course which will allow each to train one another. They will both be signing up for the 5/23/19 Face to Face Certified Medication Administration Training being held in State College, PA. |
05/23/2019
| Implemented |
| 2380.173(9) | REPEAT from 10/20/17 annual inspection: Individual #1's identification sheet and Individual Support Plan (ISP) in their record indicated the individual has allergies to Cephalexin and poison ivy. The individual's 12/7/17 physical examination only included allergies to Cephalexin.
--Individual #1's 2018 assessment indicates "his/her seizures have been under control and he/she has no problems with them." The individual's 2017 and 2018 physicals do not include a seizure disorder diagnosis. The individual's ISP indicated the individual "doesn't have a seizure disorder but a seizure protocol is in place if he/she has any seizures." | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | This regulation is important because all documents need to be consistent to allow for continuity of care across all supports provided. Inconsistencies can lead to outdated practices that jeopardizes the health, safety and welfare of the individual being served.
REPEAT from 10/20/17 annual inspection: Individual #1's identification sheet and Individual Support Plan (ISP) in their record indicated the individual has allergies to Cephalexin and poison ivy. The individual's 12/7/17 physical examination only included allergies to Cephalexin.
--Individual #1's 2018 assessment indicates "his/her seizures have been under control and he/she has no problems with them." The individual's 2017 and 2018 physicals do not include a seizure disorder diagnosis. The individual's ISP indicated the individual "doesn't have a seizure disorder but a seizure protocol is in place if he/she has any seizure REPEAT from 10/20/17 annual inspection: Individual #1's identification sheet and Individual Support Plan (ISP) in their record indicated the individual has allergies to Cephalexin and poison ivy. The individual's 12/7/17 physical examination only included allergies to Cephalexin.
--Individual #1's 2018 assessment indicates "his/her seizures have been under control and he/she has no problems with them." The individual's 2017 and 2018 physicals do not include a seizure disorder diagnosis. The individual's ISP indicated the individual "doesn't have a seizure disorder but a seizure protocol is in place if he/she has any seizures."s."
The program specialist had information listed in the 2018 that was inaccurate and this information was copied over into the ISP document which made information in the ISP inaccurate.
The program specialist made a phone call to Individual #1¿s mother to confirm whether Individual #1 has ever had a seizure or has as history of seizures. Individual #1's mom stated that he had never had a seizure nor does he have a history. Please see (Attachment 6a). Corrections were made to |
12/28/2018
| Implemented |
| 2380.181(a) | Individual #1's date of admission to the facility was 11/27/17 and an assessment was not completed until 2/27/18, over 60 calendar days after admission. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | This regulation is important because the individual, along with team members need to be updated within 60 calendar days to assure that the individual¿s health, safety and welfare needs are documented in a timely fashion. If this isn¿t done in a timely fashion the individual and team members could miss out on valuable information that is pertinent to the health, safety and welfare of the individual being served.
Individual #1's date of admission to the facility was 11/27/17 and an assessment was not completed until 2/27/18, over 60 calendar days after admission.
Program Specialist, Ashley Shawver, didn¿t calculate the correct amount of days from admission to when the assessment was completed resulting in the assessment being completed past the 60 day guideline per regulation 2380.181(a).
An Initial Assessment due date was added to the CCC Annual Due Date Checklist. New admissions will be added to the Annual Due Date Checklist upon admission and include the date of the initial assessment and annual assessment. The Program Specialist will be charged with updating the annual checklist for new admissions and then annually thereafter.
A training was held with all agency Program Specialist (Attachment #3a) on January 7, 2019 to go over the revisions of the CCC Annual Due Date Checklist that now includes a section for the initial assessment. A copy of the revised checklist is attached (Attachment #3b) |
01/07/2019
| Implemented |
| 2380.181(e)(9) | Individual #1's 2/27/18 assessment only included the individual's diagnosis of Mild Intellectual and Developmental Disabilities, high triglycerides, and high cholesterol. According to the individual's 2017 physical examination form, the individual is also diagnosed with Dyslipidemia, Moderate ID, Adjustment Disorder with depressed mood, Vitamin D Deficiency, abnormal gait, and an allergy to Cephalexin. According to the individual's Individual Support Plan (ISP) he/she is also allergic to poison ivy.
--Individual #3's 6/22/18 assessment did not include the individual's allergy to Vimpat. Individual #3's allergy to Vimpat was included in their ISP, identification sheet in their record and on their 1/2/17 physical examination form. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | This regulation is important because the individual along with team members need to have knowledge of the individual¿s disability, including functional and medical limitations so that the individual, team members and Direct Support Professionals can provide the proper supports to assure the individuals health, safety and welfare is being met.
Individual #1's 2/27/18 assessment only included the individual's diagnosis of Mild Intellectual and Developmental Disabilities, high triglycerides, and high cholesterol. According to the individual's 2017 physical examination form, the individual is also diagnosed with Dyslipidemia, Moderate ID, and Adjustment Disorder with depressed mood, Vitamin D Deficiency, abnormal gait, and an allergy to Cephalexin. According to the individual's Individual Support Plan (ISP) he/she is also allergic to poison ivy.
--Individual #3's 6/22/18 assessment did not include the individual's allergy to Vimpat. Individual #3's allergy to Vimpat was included in their ISP, identification sheet in their record and on their 1/2/17 physical examination form.
Program Specialist Ashley Shawver didn¿t update Individual #1¿s 2018 Assessment accurately to include past medical diagnosis from the 2017 physical that included Dyslipidemia, Adjustment Disorder with depressed mood, Vitamin D Deficiency, abnormal gait, and an allergy to Cephalexin.
Program Specialist Brianna Ebersole made a typing error on Individuals #3 assessment by typing ¿Yimpat¿ instead ¿Vimpat¿ which makes the assessment inaccurate.
Program Specialist Ashley Shawver completed an addendum to Individual
#1¿s 2/27/18 on 12/28/18 to include the correct diagnosis as they are listed in the past 2017 physical examination and current ISP. Please see (Attachment #4a) that demonstrates the changes made to the 2/28/18 assessment.
Program Specialist Brianna Ebersole updated the Individual #3¿s 6/22/18 assessment by completing an addendum to correct the typing error. Please see (Attachment #4b) that demonstrates she completed the addendum.
Procedures where developed to assist Program Specialist with checking for content discrepancies across reports. (Attachment #4c) explains these steps in detail to eliminate any future discrepancies. Program Specialist were also retrained on these practices on 1/7/19 (Attachment #4d) |
12/28/2018
| Implemented |
| 2380.181(e)(10) | Individual #1's 2/27/18 assessment did not include a lifetime medical history attached to the assessment. | The assessment must include the following information: A lifetime medical history. | A lifetime medical should be attached to each assessment to allow the individual and team members to observe current and past medical information that is pertinent to the development of the Individual Support Plan. This will allow all parties to be up to date on any medical information that assures the health, safety and welfare of the individual being served.
Individual #1's 2/27/18 assessment did not include a lifetime medical history attached to the assessment.
When the Program Specialist wrote Individual #1¿s assessment she titled the document ¿Medical History Update¿ which indicates that it wasn¿t the original and complete medical history.
Compass Community Connections has changed the format of their medical history document which now includes more complete and formal medical history that will be updated annually with the assessments.
The updated medical history document will be used and the Program Specialist will attach the medical history to the initial and annual assessments. Please see (Attachment 5a) of Individual #1¿s current assessment to demonstrate use of new lifetime medical history document. |
09/25/2018
| Implemented |
| 2380.186(a) | Individual #1's Individual Support Plan (ISP) review covering the period from February to April 2018 was not completed until 5/28/18. The individual's ISP review covering the period from May to June 2018 was signed and dated by the program specialist or the individual; thus not completed. Individual #1's ISP review covering the period from November 2017 to January 2018 wasn't completed until 2/27/18. | 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. | This regulation is important because the individual¿s needs could change and the individual/team/parent/guardian should be updated at least every 3 months by the Program Specialist on changes to the ISP as it relates to outcomes linked to services that are provided by Compass Community Connections Marcella Ganoe Center.
Individual #1's Individual Support Plan (ISP) review covering the period from February to April 2018 was not completed until 5/28/18. The individual's ISP review covering the period from May to June 2018 was signed and dated by the program specialist or the individual; thus not completed. Individual #1's ISP review covering the period from November 2017 to January 2018 wasn't completed until 2/27/18.
Program Specialist, Ashley Shawver, wasn¿t tracking her quarterly reviews on the correct schedule which lead her to scheduling meetings beyond the 15 day grace period allowed for quarterly reviews.
A training was held on January 7, 2019 with Program Specialist Ashley Shawver from the Marcella Ganoe Center to review regulation 2380.16(a). (See Attachment #1a). Also reviewed at the training was the Program Specialists updated Annual Due Date Checklist (Attachment #1b.) to assure that quarterly review dates are being scheduled at least every 3 months and no later than the 15 day grace period allowed by regulation. Note: Our other licensed program (Compass Corner) got cited for this same regulation on September 28, 2018 and we have already implemented changes to correct our practices. Program Specialist Ashley Shawver completed an updated Quarterly Review dated January 8, 2019 and is attached (Attachment #1b) showing compliance with this regulation.
The Annual Due Date Checklist will be kept up to date by the Program Specialist to assure that they are on schedule with the 3 month review cycle and not extending beyond the 15 day grace period. |
01/08/2019
| Implemented |
| 2380.186(e) | Individual #1's team members that included his/her mother, supports coordinator, vocational facility and habilitation worker, were not offered the option to decline the individual's Individual Support Plan (ISP) review documentation until 11/5/18. Individual #1's date of admission to the facility was 11/27/17 and ISP reviews have been completed and sent to team members prior to the team being offered the option to decline the reviews. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | All team members should be notified of the option to decline so they have the right to receive or not receive plan updates per regulation. A documented declination of the ISP Review Documentation remains in effect until/unless the team member subsequently requests the ISP Review Documentation.
Individual #1's team members that included his/her mother, supports coordinator, vocational facility and habilitation worker, were not offered the option to decline the individual's Individual Support Plan (ISP) review documentation until 11/5/18. Individual #1's date of admission to the facility was 11/27/17 and ISP reviews have been completed and sent to team members prior to the team being offered the option to decline the reviews.
Our current practices has the option to decline on our agency signature sheet which only allows for team members to check off in they are in attendance. In this case, Individual #1¿s team members weren¿t present at the initial meeting, therefore not given the option to decline until 11/5/18 almost a year after admission on 11/27/17.
The option to decline section from our agency signature sheet was removed and we will now offer the option to decline on our ISP Annual and Quarterly Review invite and enclosure letters.
An ISP Review Invitation Template (Attachment #2a) and ISP Review Enclosure Template (Attachment #2b) was developed and reviewed with all agency Program Specialist at a training on January 7, 2019 (Attachment #2c) and will be used immediately for any future ISP Annual or Quarterly Reviews. Both the ISP Review Invitation and ISP Review Enclosure includes a statement that gives team members the option to decline and will be carbon copied in the correspondence letters to assure that they are given the option to decline per regulation. (Attachment #2d) is a recent enclosure letter written by Ashley Shawver that was sent out to team members demonstrating the use of the new practice. |
01/08/2019
| Implemented |
|
|
|
SIN-00121455
|
Renewal
|
10/20/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(f) | Staff #2 fire safety was conducted on 7/12/16 and again on 7/14/17. | Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f). | Program Specialists will ensure that fire safety training for Program Specialists and direct service workers is held annually, on or before the prior year training date.
Program Specialists were trained on 10/25/17 on the responsibility to schedule fire safety training for Program Specialists and direct support staff annually. (Attachment #17) |
10/25/2017
| Implemented |
| 2380.89(a) | There was no fire drill for June 2017. | An unannounced fire drill shall be held at least once a month. | Program Specialists will ensure that an unannounced fire drill will be held at least once a month and documented of the Fire Drill record form.
Program Specialists were trained on 10/25/17 on the responsibility to have an unannounced fire drill at least once a month and to document fire drill on fire drill record. (Attachment #16) |
11/30/2017
| Implemented |
| 2380.111(c)(5) | Individual #1's phsycical dated 2/17/17 was missing the information for tuberculin skin testing. Individual #3's phsycial dated 7/1/16 and again on 4/16/14. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Program Specialist will ensure that physical examination includes immunizations up to date as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 340333. Program Specialists will give caregiver timely notice of need for updated immunizations. In the event that caregiver fails to obtain the immunization by due date including grace period, individual will be excluded from attending day program until the immunization is up to date.
Letter written by Program Director was sent home with each Individual. Letter addresses need for TB test to be completed by grace period or Individual is excluded until is completed. (Attachement #14)
Program Specialists were trained on 10/25/17 on the responsibility to ensure immunizations are current. (Attachment #15) Immunizations on all other physicals were reviewed to ensure compliance. |
11/30/2017
| Implemented |
| 2380.173(9) | Individual #3's assessment dated 2/17/17 states individual assistance to utilize the bathroom. The ISP updated on 6/12/17 states indepenence utilize the bathroom. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | Program Specialists will ensure that each Individual¿s record includes no content discrepancies in the ISP, the annual update or revision.
Program Specialists were trained on looking for content discrepancies in the ISP on 10/25/17. (Attachment #12)
Program Specialist emailed SC for Individual #3 requesting that the ISP be updated to include the assistance needed in the restroom. (Attachment #13
All Individual files reviewed. Program Specialist will email any content discrepancies found to the assigned SC for the ISP to be updated. |
12/15/2017
| Implemented |
| 2380.177 | Individual #2's record did not contain the consent for information to be release of information, including photographs, to persons not otherwise authorized to receive it. | Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. | Program Specialist will ensure that the Individual/Parent/Guardian sign a written consent to release information, including photographs, to persons not otherwise authorized to receive it.
Release of information developed and is being sent home with all program participants for signature. Any new individuals will receive consent to sign upon admission to the program. Individual #2 returned signed copy of consent (Attachment #10)
Program Specialists were trained 10/25/17, on the need for written consent to release information, including photographs, to persons not otherwise authorized to receive it. (Attachment #11) |
12/15/2017
| Implemented |
| 2380.181(e)(4) | Individual #3's assesment dated 2/17/17 has 15 minute unsupervised time. It does not give details. It also states they require supervision while utilizing the bathroom; it does not give any details as to utilization. | The assessment must include the following information: The individual¿s need for supervision. | Program Specialist will ensure that the assessment addresses the Individual¿s need for supervision, including details for any unsupervised time and details on utilization.
Program Specialists were trained on 10/25/17 on the need to address supervision needs in the assessment. (Attachment #7)
Assessment for Individual #3 was updated to clearly reflect supervision needs. (Attachment #8)
All Assessments were reviewed. Any Assessments that do not clearly address supervision time at day program will be updated. Update will be distributed to ISP Team. |
12/15/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #3's assessment dated 2/17/17 did not include progress over the last 365 calendar days and current level in socialization. | 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. | Program Specialist will ensure that the assessment contains progress over the last 365 days and current level in the area of socialization.
Program Specialists were trained on 10/25/17 on the need for progress and current level of socialization is addressed in the assessment. (Attachment #7)
Assessment for Individual #3 was updated to reflect progress and current level in the area of Socialization. (Attachment #9)
All Assessments were reviewed. Any Assessments that do not clearly address progress over last 365 days and current level of socialization will be updated. Update will be distributed to ISP Team. |
12/15/2017
| Implemented |
| 2380.183(4) | Individual #3's ISP last updated 6/12/17 does not includes 15 minutes alone time while at program. | 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. | The Program Specialist will ensure that the ISP includes supervision at the day program or in the community as identified in the Individual¿s assessment. SC for Individual #3 was contacted to include in the ISP protocol and schedule outlining specified periods of time for the Individual to be without direct supervision at day program as identified in the assessment. Alone time was updated as Individual #3 has a seizure disorder. Seizure Protocol indicates to call 911 for seizures lasting more than 5 minutes. To ensure the health and safety of Individual #3, alone time is decreased to 5 minutes. (Attachment # 5)
Program Specialists were trained on 10/25/17 on the responsibility to ensure ISP include protocol and schedule outlining specified periods of time for the Individual to be without direct supervision at day program as identified in the assessment (Attachment #6)
All ISP were reviewed to ensure protocol and schedule outlining specified periods of time for the individual to be without direct supervision at day program as identified in the assessment is included. Program Specialist will contact SC to include this information in any ISP that does not clearly identify periods of unsupervised time. |
12/15/2017
| Implemented |
| 2380.186(c)(2) | Individual #2's ISP reviewed has 15 minutes alone time in the program yard with staff to check through windows. This is not being reported on the individual ISP reviews dated 10/16/17, 7/13/17, 7/14/17, and 1/16/17. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Program Specialists will ensure that ISP reviews include a review of each section of the ISP specific to the facility licensed under this chapter.
Program Specialists were trained on 10/25/17 on the need to review all sections of the ISP. (Attachment #3).
October 2017 monthly report for Individual #2 reports on 15 minute alone time in the program back yard with staff checking through the window. (Attachment #4).
All Individuals¿ files reviewed. Program Specialist will report in ISP reviews on anyone that has alone time identified in the ISP. |
12/15/2017
| Implemented |
| 2380.188(a) | Individual #3's has a seizure disorder. There is no seizure protocol in place. | The facility shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | Program Specialist will ensure that a seizure protocol is in place for each Individual with a seizure disorder diagnosis.
Program Specialists were trained on 10/25/17 on the need to ensure there is a seizure protocol in place. (Attachment # 1)
Program Specialist contacted physician for Individual #3 to obtain seizure protocol. Protocol attached. (Attachment # 2)
All Individual files were reviewed. Program Specialists are making contact with the appropriate physician for seizure protocols for anyone that has a seizure diagnosis but no seizure protocol in the file. |
12/15/2017
| Implemented |
|
|
|
SIN-00095110
|
Renewal
|
09/09/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.183(5) | Individual #1's ISP current ISP dated 06/06/2016 did not include a protocol to address the social, emotional and environmental needs of the individual. Individual #1 is prescribed a psychotropic medication for a mood disorder. | 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. | Program Specialist spoke with SC on 9/14/16 requesting that the SEEP be incorporated into the ISP. Program Specialist emailed SC on 10/3/16 to remind SC of the conversation. (See attached email). Program Specialists will review the ISP for all program participants to ensure that the SEEP is incorporated into the ISP. SC will be notified via email of the need to incorporate the SEEP, if it is not included. |
10/14/2016
| Implemented |
|
|
|
SIN-00080305
|
Renewal
|
06/17/2015
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(f) | Staff #7 had fire saftey training on 10/1/2013 and then should have had it again on 9/30/2014. Training was outside of annual time frame. | Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f). | Staff #7 will be trained on fire safety. Program Specialists will schedule annual training by fire safety expert for all staff. Staff that is not present on date of training will be trained by Program Specialist upon return to work.
In the event that a staff transfers from one program to another, Program Specialist will review fire safety training with that staff member on the first day of work and complete attached form to verify that the training was completed.
Program Specialists are responsible to ensure staff is trained annually.
Program Director will provide training to Program Specialists on the requirement to schedule annual training for staff with fire safety expert per regulations.
|
07/31/2015
| Implemented |
| 2380.124a | Individual #3's June MAR does not match the medication bottle for Primidone 250mg. MAR says 3 times a day and every other day give a fourth dose. Medication bottle states to give 3 times a day. | The medication log must identify the prescribing certified registered nurse practitioner (CRNP) when a medication was prescribed by a CRNP as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners). | Medication Administration Certified Trainer will retrain all medication administration certified staff on the 5 rights of Medication Administration, proper completion of MAR and proper discontinuation of a medication.
Upon receipt of new bottle of medication, two staff trained in medication administration will look at the label on the bottle and compare to the label on the MAR. On the back of the MAR, in the note section, staff will document that label matches the MAR and initial. If there is a discrepancy, staff will immediately notify the Program Specialist for the Program Specialist to verify that the order has changed. Once verified, staff will make the proper changes to the MAR to reflect the new order as trained in Medication Administration Training.
Medication Administration Certified Trainer, in the process of mandated review of MAR, will note any discrepancies between label and MAR. If any discrepancies are found, this will result in immediate suspension of all trained staff to administer medication until all staff has completed the entire Medication Administration course. This is in accordance to existing policy on medication administration. |
07/31/2015
| Implemented |
| 2380.183(7)(i) | Individual #1 and #3's ISP did not include the potential to advance in vociational 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. | Program Specialists will review all ISP to ensure that area of potential to advance in vocational programming is incorporated into the ISP. Program Specialist will contact SC via email to request this information be included in the ISP, if missing. Program Specialist will maintain copy of email in individual¿s file as verification that this was done.
At all future annual ISP meetings, Program Specialist will ensure that area of potential to advance in vocational programming is incorporated into the ISP. If content not present, Program Specialist will contact SC via email to request the information be included and again maintain a copy of the email in the individual¿s file.
Program Director will provide training to Program Specialists regarding the review of all content in the ISP.
Program Director will meet with SCO to discuss this regulation and the requirement for the needed content in the ISP to show potential to advance in vocational programming.
|
08/31/2015
| Implemented |
| 2380.183(7)(iii) | Individual #1's ISP did not include the potential to advance in competitive 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. | Program Specialists will review all ISP to ensure that area of potential to advance in competitive community-integrated employment is incorporated into the ISP. Program Specialist will contact SC via email to request this information be included in the ISP, if missing. Program Specialist will maintain copy of email in individual¿s file as verification that this was done.
At all future annual ISP meetings, Program Specialist will ensure that area of potential to advance competitive community-integrated employment is incorporated into the ISP. If content not present, Program Specialist will contact SC via email to request the information be included and again maintain a copy of the email in the individual¿s file.
Program Director will provide training to Program Specialists regarding the review of all content in the ISP.
Program Director will meet with SCO to discuss this regulation and the requirement for the needed content in the ISP to show potential to advance competitive community-integrated employment.
|
08/31/2015
| Implemented |
|
|
|
SIN-00067181
|
Renewal
|
06/11/2014
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.181(a) | The assessment for Individual #2 was not completed annually, 12/7/12 -12/9/13. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Program Specialist will ensure that every individual has an initial assessment within one year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. Program Specialist completed an assessment for another individual at the ATF and updated the assessment annually thereafter. See attached assessments for 2013 and 2014 to reflect the assessment was completed in compliance with the regulations. |
10/31/2014
| Implemented |
|
|
|
SIN-00049170
|
Renewal
|
06/06/2013
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.181(e)(13)(ii) | Individual #1's annual assessment did not include progress and growth in Motor and communication skills, personal adjustment, socialization and community intergration. | (e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas: (ii) Motor and communication skills. | Partially Implemented/Adequate Progress CSS 7-2-13
Individual#1's annual assessment was updated to include progress in motor & communication skills. Validation to be submitted by email. Future assessments for all individuals served will include progress over the last 365 calendar days in all assessment areas. |
06/17/2013
| Implemented |
|
|
|
SIN-00043692
|
Renewal
|
12/28/2012
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(6) | The physical examination for Individual #1 did not indicate the communicable disease status. | (c) The physical examination shall include:(6) 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. | Partially Implemented, Adequate Progress- CSS
Program Specialist will thoroughly review all physical exam documents to insure completion of all areas including communicable disease status. Program Specialsit will contact physicians office for any incomplete information.See attached physical for Individual #1 with completed status of communicable disease. |
01/11/2013
| Implemented |
| 2380.181(e)(12) | There were no recommendations for specific areas of training, vocational programming and competitive community-integrated employment in the annual assessment for Individual's #1, #2 and #3.
| (e) The assessment must include the following information: (12) Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Partially Implemented-Adequate Progress-CSS
Any assessment completed will include recommendations for specific areas of training, vocational programming & competitive community integrated employment. See attached copy of pg. 15 of provider assessment that includes these areas. The next assessment completed will be forwarded for validation. please note: Next assessment not due until March 2013. |
01/02/2013
| Implemented |
| 2380.186(c)(2) | There was no documentation in the Quarterly ISP reviews that the support plan for Individual #2 was reviewed. | (c) The ISP review must include the following: (2) A review of each section of the ISP specific to the facility licensed under this chapter. | Partially Implemented, Adequate Progress- CSS
Program Specialist will review support plan on a quarterly basis. Please refer to corrected support plan for individual #2.
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01/02/2013
| Implemented |
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SIN-00237657
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Renewal
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02/07/2024
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Compliant - Finalized
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