| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(6) | Individual #1's physical examination on 10/14/20 indicated that individual was not free of communicable diseases, and did not contain instructions for specific precautions to be taken to prevent the spread of the disease to other individuals. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | Program Supervisor and Assistant Supervisor will review that all physical forms are completed in full and state that the individual is ¿free of communicable disease¿. If the physical form is not completed in full, the Program Supervisor or Assistant Supervisor, will reach out to the MD for an updated physical exam to be completed in its entirety. If an individual is not free from communicable disease, the Program Supervisor and Assistant Supervisor will identify to program staff, during a staff meeting, the specific precautions to prevent the spread of disease to other individuals. Program Director will document the re-education to Program Supervisor and Assistant Supervisor to guarantee all requirements are being followed for regulation 2380.111(c)(6). [As soon as safe and feasible (due to COVID), the CEO or designee, educated in the requirements of individual's physical examinations, shall implement the aforementioned procedures to obtain an updated physical examination document to accurately address communicable disease for Individual #1. Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examination to ensure all required information is included including addressing communicable disease. Missing information shall be immediately obtained. Documentation of all audits of physical examination and efforts to obtain missing information shall be kept. (DPOC by AES,HSLS on 1/11/21)] |
01/29/2021
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination on 10/14/20 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Supervisor and the Assistant Supervisor will both review the physical form to ensure its completion so there is a check and balance. Program Supervisor and Assistant Supervisor will review that all physical forms per individual, include `¿all medical information pertinent to diagnosis and treatment in case of emergency¿¿. If the physical form is missing information pertinent to diagnosis and treatment in case of emergency, the Program Supervisor or Assistant Supervisor, will contact the MD for an updated physical exam to be completed. Program Director will document the re-education to Program Supervisor and Assistant Supervisor to ensure all requirements are being completed for regulation 2380.111(c)(10) [As soon as safe and feasible (due to COVID), the CEO or designee, educated in the requirements of individual's physical examinations, shall implement the aforementioned procedures to obtain an updated physical examination document to accurately address medical information pertinent to diagnosis and treatment in case of an emergency for Individual #1. Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examination to ensure all required information is included including addressing medical information pertinent to diagnosis and treatment in case of an emergency. Missing information shall be immediately obtained. Documentation of all audits of physical examination and efforts to obtain missing information shall be kept. (DPOC by AES,HSLS on 1/11/21)] |
01/29/2021
| Implemented |
| 2380.36(b) | Direct Service Worker #1 received annual training by a fire safety expert on 04/17/19, and then again on 05/04/20. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Administrator will maintain an annual training log and an outlook calendar, which will identify the training dates for upcoming fire safety requirements for staff. Program Supervisor will review monthly with Admins to ensure all staff complete training requirements. During supervision, Program Supervisor will review monthly training logs with Admin to ensure all staff are up to date with Fire Safety Trainings per regulation 2380.36(b). [Documentation of the aforementioned audits/reviews shall be kept. (AES,HSLS on 1/11/21)] |
01/29/2021
| Implemented |
| 2380.181(f) | The program specialist provided Individual #2's assessment, completed 08/07/20 to the individual plan team members on 08/07/20 for an individual plan meeting that occurred on 08/17/20. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The annual assessment will be completed at the 3rd quarter ISP review to ensure that it is completed and sent within 30 days of the annual ISP meeting. A letter is sent out to the plan team documenting that the ISP quarterly or annual review was completed and that the assessment was also sent out. This documentation is kept in the consumer chart in the correspondence section. Supervisors will maintain their monthly due date checklists that include ISP quarterly review dates, assessment due dates and Annual ISP due dates. These due date checklists are reviewed by the assistant supervisor and program supervisor monthly. [Documentation of the aforementioned audits/reviews shall be kept. (AES,HSLS on 1/11/21)] |
01/29/2021
| Implemented |