| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Dish wishing liquid, mop and glo, miracle glow, and other cleaners indicating to contact poison control if ingested were unlocked on and under the kitchen sink. Not all individuals in the program are safe with poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Program Specialists and all direct support staff are responsible to ensure that poisonous materials are locked. All poisonous materials are locked currently. New dish soap that does not have a warning to contact poison control was purchased. Furthermore, a poisonous materials check will be conducted every morning prior to the arrival of individuals to ensure that the program area is safe. (Attachment #21)
All staff were trained on 9/25/17 on the requirement to keep poisonous materials locked and the procedure to conduct poisonous materials check every morning prior to program hours. (Attachment #22) |
09/25/2017
| Implemented |
| 2380.87(b) | The first aid area is not equipped with a fire alarm/strobe. Deaf individuals attend this program. The main program area contains an alarm/strobe however, if individuals are in the locker area or near the restroom area, the strobe is not visible from those areas of the room. | 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. | Program Specialist will meet with Individual and his family to discuss Individual¿s ability to see the strobe light from the locker area and area outside of the bathrooms. If Individual indicates that he can see the strobe light, Individual and family will sign written documentation of this, which will be maintained in the Individual¿s file. If Individual indicates that he cannot see the strobe light, Program Specialist will work with family to purchase a personal warning device that activates when the fire alarm activates. Individual will wear the device when attending day program.
First Aid area will be moved to a room across the hall from program area that has a strobe light. This room is currently used to provide personal care to day program individuals. It has a bed, pillow, blanket plus toilet, sink and shower. First Aid kit and manual will be put in this room. |
10/31/2017
| Implemented |
| 2380.89(c) | The 7/27/17 fire drill log did not indicate if all alarms were operative. | 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. | Program Specialists will ensure that fire drill record clearly contains the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fired alarm was operable.
Program Specialists were trained on 9/25/17 on the responsibility to ensure fire drill record is completed accurately and in it¿s entirety. (Attachment #19) |
09/25/2017
| Implemented |
| 2380.89(g) | The 10/10/16 fire drill log indicated Individual #3 refused to evacuate the building during the drill. A second drill was not completed in October. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Program Specialist will ensure that a second fire drill is completed should someone not evacuate for any reason.
Program Specialists were trained on September 25, 2017 on the requirement to hold a second fire drill that month in the event that someone fails to evacuate. (Attachment #20) |
09/25/2017
| Implemented |
| 2380.111(c)(3) | Individual #2's 6/12/17 physical indicated immunizations were last completed on 7/18/07. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | 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, individual will be excluded from attending day program until the immunization is up to date. Individual #2 did obtain immunization once caregiver was given a time frame of two weeks to have immunization done and informed that the individual could not attend day program after that date, if the immunization was not done. (Attachment #16 and #17) |
09/25/2017
| Implemented |
| 2380.128(a) | Staff #2 passed medications on 5/24/17 and was not trained in the Department's medication administration course. | 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. | Medication Administration Trainer and Program Director will jointly ensure that staff are trained in the Department¿s medication administration course before dispensing any medications. For a new hire coming from another provider, Medication Administration Trainer and Program Director will obtain documentation of successful completion of the Department¿s medication administration course from the other provider. If current, the staff member will be trained on the MJSNC medication administration policy. Additionally, two medication observations will be completed prior to the new staff administering medication.
Mifflin-Juniata Special Needs Center Medication Administration Policy is updated to clearly reflect the above. (Attachment #15)
In the event of a new staff never trained in the Department¿s medication administration course, Medication Administration Trainer will enroll staff member in the course, monitor the completion of the online modules and conduct the face-to-face training and testing, as required by the Department¿s medication administration course.
There are currently three new staff in process of completing the Department¿s medication administration online course. Once face-to-face training is completed and staff successfully pass the course, documentation of this will be provided to BHSL.. This includes Staff #2. |
11/30/2017
| Implemented |
| 2380.176(a) | Communication logs and Individual Support Plans were unlocked in the kitchen cabinet. | Individual records shall be kept locked when they are unattended. | Program Specialists will ensure that individual records are kept locked when they are unattended. ISP for staff review and communication logs are now kept in locked cupboard.
Program Specialists were trained on 9/25/17 on the requirement of records being kept locked when unattended. (Attachment #14) |
09/25/2017
| Implemented |
| 2380.177 | All individual records did not include a consent to release information form. Consent to release information was not obtained from the individuals. | 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 (Attachment #12)
Two out of the three Program Specialists were trained on September 27, 2017on the need for written consent to release information, including photographs, to persons not otherwise authorized to receive it. The third will be trained upon return from a four day off site CPI Trainer Training. (Attachment #13) |
10/31/2017
| Implemented |
| 2380.181(a) | Individual #2's initial assessment was completed late. Individual #2 was admitted to the program on 6/26/17. The initial assessment was completed on 8/28/17. | 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 initial assessment is completed within 1 year prior to or 60 calendar days after admission to the facility and updated assessment annually thereafter.
Program Specialists were trained on 9/25/17 on the responsibility to complete the initial and annual assessments as required by regulation. (Attachment #5)
All other assessments were reviewed and found to be in compliance.
Program Director will review all initial and annual assessments for the next six months to ensure that the assessments are completed on time. Program Director will provide ongoing training as needed to the Program Specialists on proper completion of the assessment. |
09/25/2017
| Implemented |
| 2380.181(e)(4) | Individual #2's 8/28/17 assessment indicated Individual #2 could be left alone for one hour or more. The assessment did not assess how long Individual #2 could be left alone before staff members need to check on him/her. | The assessment must include the following information: The individual¿s need for supervision. | Program Specialist will ensure that assessments assess individual¿s need for supervision including how long an individual can be left alone before staff members need to check on him/her when individual has independent time. Assessment for Individual #2 was revised to capture true supervision at day program. The orginigal assessment confused what grandmother reported for time alone at home with time alone at day program.(Attachment #6)
Program Specialists were trained on 9/25/17 on the need assess need for supervision and to assess how long an individual may be left alone before staff members need to check on him/her when there is alone time while at day program. (Attachment #5)
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 at one time with any other updates needed due to licensing.
Program Director will review all initial and annual assessments for the next six months to ensure that the required information is documented. Program Director will provide ongoing training as needed to the Program Specialists on proper completion of the assessment. |
10/31/2017
| Implemented |
| 2380.181(e)(5) | Individual #1's 5/5/17 assessment did not include his/her ability to self-administer medications. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Program Specialist will ensure that ability to self-administer medications is identified on the assessment. Assessment for Individual #1 was revised to include her ability to self-administer medication. (Attachment #7)
Program Specialists were trained on September 25, 2017 on the responsibility to include ability to self-administer medication in the assessment. (Attached #5)
All assessments were reviewed. Any assessments that did not address ability to self-administer medication will be updated. Updates will be sent to ISP Team at one time with any other updates needed due to licensing.
Program Director will review all initial and annual assessments for the next six months to ensure that the required information is documented. Program Director will provide ongoing training as needed to the Program Specialists on proper completion of the assessment. |
10/31/2017
| Implemented |
| 2380.181(e)(7) | Individual #1's 5/5/17 assessment did not include his/her knowledge of heat sources or his/her 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. | Program Specialist will ensure that assessments include knowledge of danger of heat sources and ability to sense and move away quickly from heat sources, which exceed 120 ¿F and are not insulated. Assessment for Individual #1 was updated to include her knowledge of heat sources and ability to sense and move away quickly. (Attachment #8)
All assessments were reviewed. It was found that none of the assessments addressed the knowledge of the danger of heat sources. All assessments will be updated to include this requirement. Updates will be sent to ISP Team at one time with any other updates needed due to licensing.
Program Specialists were trained on 9/25/17 on the responsibility to address knowledge of danger of heat sources and ability to move away quickly. (Attachment #5)
Program Director will review all initial and annual assessments for the next six months to ensure that the required information is documented. Program Director will provide ongoing training as needed to the Program Specialists on proper completion of the assessment. |
10/31/2017
| Implemented |
| 2380.181(e)(12) | Individual #2's 8/28/17 assessment did not include recommendations for specific areas of training, vocational programming, or competitive employment. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Program Specialist will ensure that recommendations for specific areas of training, vocational programming and competitive community integrated employment is addressed on the assessment. Assessment for Individual #2 was revised to include this information (attachment #9)
All assessments were reviewed and found to be in compliance.
Program Specialists were trained on 9/25/17 on the requirement to include recommendations for specific areas of training, vocational programming and competitive community integrated employment on the assessment..(Attachment #5)
Program Director will review all initial and annual assessments for the next six months to ensure that the required information is documented. Program Director will provide ongoing training as needed to the Program Specialists on proper completion of the assessment. |
09/25/2017
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's 5/5/17 assessment did not include progress or regression over the past year in community integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | Program Specialist will ensure that the assessment includes progress and current level in the community integration. Assessment for Individual #1 was updated to clearly reflect this requirement. (Attachment #10)
All assessments were reviewed. Any assessments that do not clearly reflect the progress and growth in community integration will be updated. Updates will be sent to ISP Team at one time with any other updates needed due to licensing.
Program Specialists were trained on September 25, 2017 in responsibility to ensure progress and growth in community integration is included in all assessments. (Attachment #5)
Program Director will review all initial and annual assessments for the next six months to ensure that the required information is documented. Program Director will provide ongoing training as needed to the Program Specialists on proper completion of the assessment. |
10/31/2017
| Implemented |
| 2380.181(e)(14) | Individual #2's 8/28/17 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. | The Program Specialist will ensure that the Assessment indicates if the Individual can or cannot swim. Assessment for Individual #2 was revised to accurately identify that the Individual is able to swim. (Attachment #11).
All Assessments were reviewed. Any Assessments that do not clearly indicate if the Individual can or cannot swim were updated to make this information clear. Update will be distributed to ISP Team at one time with any other updates needed due to licensing.
Program Specialists were trained on September 25, 2107 on the responsibility to ensure that ability to swim is properly identified in the assessment. (Attachment #5).
Program Director will review all initial and annual assessments for the next six months to ensure that the required information is documented. Program Director will provide ongoing training as needed to the Program Specialists on proper completion of the assessment. |
10/31/2017
| Implemented |
| 2380.183(4) | Individual #2's Individual Support Plan (ISP) did not include his/her required supervision at the day program or 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. | : 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.
Plan of Correction:
The Program Specialist will ensure that the ISP includes supervision at the day program or in the community. SC was contacted to include supervision at day program and in the community in the ISP for Individual #2. SC updated the ISP for Individual #2. (Attachment #3)
Program Specialists were trained on 9/25/17 on the responsibility to ensure supervision at day program and the community is in the ISP. (Attachment #4)
All other ISP were reviewed and include supervision section.
The Program Specialist will ensure that the ISP for any new referrals includes supervision at day program and in the community. |
09/18/2017
| Implemented |
| 2380.186(c)(1) | Individual #1's Individual Support Plan (ISP) reviews did not include progress towards the ISP outcome of community involvement. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | The Program Specialist will ensure that the ISP reviews document participation and progress during the past 3 months toward ISP outcome supported services provided by the facility. The August monthly review for Individual #1 was revised to accurately document the outcome and progress towards the outcome. (Attachment #1)).
All ISP reviews were reviewed and found to be in compliance.
Program Specialists were trained on September 25, 2017 on the responsibility to document progress on the ISP outcome in ISP reviews. (Attachment #2) |
09/25/2017
| Implemented |