Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224741 Renewal 06/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(4)On 7/24/22 and 6/17/23 an email request was sent out to the Supports Coordinator requesting that the supervision level for individual #2 in the Individual Plan be corrected from saying individual #2's supervision level is 1:2-1:6 to 1:4-1:6; however, the current assessment (8/9/22) still reads that individual #2's supervision level is 1:2-1:6.The assessment must include the following information: The individual¿s need for supervision.All staff were retrained on 55 PA Code 181 (e) 4 (Attachment #1) The ISP and Assessment have been updated to reflect the correct ratio and supervision as evidenced in Attachment #4 &5. 07/17/2023 Implemented
2380.181(e)(10)Individual #1's medical history 1/23/23 states a regular diet and thin liquids is to be followed. Individual #1 currently follows a 1300 calorie, low carbohydrate pureed diet.The assessment must include the following information: A lifetime medical history.All staff were retrained on 55 PA Code 181 (e) 10 (Attachment #1 ) The ISP and Lifetime Medical History section of the Assessment have been updated to reflect the correct dietary needs as evidenced in Attachment #4 & 6. 07/17/2023 Implemented
2380.183(a)(3)The Individual Plan meeting held on 10/11/22 for Individual #2 did not have a Direct Support Professional from day program present at the meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.All staff were retrained on 55 PA Code 181 (e) 10 (Attachment #2) 07/17/2023 Implemented
2380.183(a)(4)The Individual Plan meeting held on 10/11/22 for individual #2 did not have a Program Specialist from the day program present at the meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The program specialist.All staff were retrained on 55 PA Code 183(a)4 (Attachment #2) 07/17/2023 Implemented
2380.186Individual #1's Individual Plan 3/28/23 states a regular diet and thin liquids is to be followed. Individual #1 currently follows a 1300 calorie, low carbohydrate pureed diet.The facility shall implement the individual plan, including revisions.All staff were retrained on 55 PA Code 181 (e) 10 (Attachment #1 ) The ISP and Lifetime Medical History section of the Assessment have been updated to reflect the correct dietary needs as evidenced in Attachment #4 & 6. 07/17/2023 Implemented
SIN-00190371 Renewal 07/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(4)Staff #1's physical exam dated 9/25/20 does not indicate whether there are any medical problems which might interfere with the health and safety of individuals at the facility.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.All staff were retrained on 2380.113(c)(4) (Attachment #1) Staff #1: Physical has been corrected by the Physician. (Attachment #3 ) 08/19/2021 Implemented
2380.21(u)Individual #1 was admitted to the program on 3/30/2021 but did not sign off on their rights and releases until 7/20/2021. Individual #2 was admitted to the program on 1/30/2000. Their rights were signed on 2/5/2020 and not again until 6/14/2021. The provider was closed due to COVID until March of 2021. Individual's rights should have been completed and signed upon immediate return after the COVID closure ended in March to remain in compliance, but they weren't signed until 3 months later in June of 2021.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.All staff were retrained on 2380.21(u) (Attachment #2 ) 08/19/2021 Implemented
SIN-00174465 Renewal 08/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 had a Tuberculin Skin Test on 11/10/2017 and then again on 11/27/2019.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 and all staff have been trained on 55 PA Code Chapter 2380.111(C)5. (Attachment #1). Supervisor will ensure that all TB tests are completed timely for all individuals receiving services using the participant due date tracker. (Attachment #2). Quarterly audits will be completed internally to review and confirm compliance with regulations. (Attachment #3). 08/25/2020 Implemented
2380.183(a)(3)Individual #2 did not have a DSP at their 2/4/2020 ISP meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.Program Specialist and all staff have been trained on 55 PA Code Chapter 2380.183(a)3. (Attachment #1). Supervisor will ensure that a DSP is present at all ISP meetings. (Attachment #4). The supervisor will document if the DSP is not able to attend and the reason why. If the DSP is not able to attend in person, a phone conference may be used. If attending in person or by phone is not feasible, the DSP will be asked to provide their input in writing on the form created for this purpose. (Attachment #5). Quarterly audits will be completed internally to review and verify compliance of program regulations. (Attachment #4) 08/25/2020 Implemented
SIN-00154452 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16(continued from previous violation page) The individual's seizure log documented that she continued to have 33 documented seizures on 12/28/19 at program. From 8:16am-8:31am she had more than 5 seizures lasting over 10 seconds long. Her Diazepam was administered at 8:36am. However, staff documented that the individual continued to have seizures 30 minutes after her first dose of Diazepam. Her second dose of Diazepam was not administered until 10:35am even though it should have been administered at 9:10am; 30 minutes after her dose of Diazepam and still having seizures. According to her seizure logs, she was still seizing 30 minutes after her 2nd dose of Diazepam. A 3rd dose of Diazepam was never administered and 911 was never called. Individual #1 had documented 33 seizures throughout the entire day on 12/28/18 and medical attention was never sought. This occurred less than one day after the individual was hospitalized due to an increased number and length of seizures at the day program the previous day. The agency did not have documentation of follow up action or medical discharge instructions to follow after the individual was hospitalized on 12/27/18.This applies to abuse occurring at the facility. Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse. Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview Duplicate 08/31/2019 Implemented
2380.16Individual #1's Diazepam medication label and 12/31/18 doctor ordered seizure protocol stated to "administer 5mg (1ml) for greater than 2 seizures lasting longer than 30 sec in one hr (or for greater than 5 seizures (lasting more than 10 sec) in one day." The individual's 12/31/18 doctor's ordered seizure protocol indicates, " If still having seizure activity after 30 min can give another dose. If still having seizure activity after an additional 30 min, can give a 3rd dose and call 911 for patient to be evaluated in the ER." According to the individual's seizure log for 4/5/19, it was documented that the individual had 10 documented seizures from 8:25am to 10:50am lasting anywhere from 8 seconds to 30seconds. Six seizures lasting more than 10 seconds occurred from 8:25am until 9:28am. Diazepam was not administered until 10:55am, over an hour after the doctor's order. Then, the individual's seizure log stated that the individual continued to have seizures at 9:31am, 10:43am and 10:55am. An additional dose of Diazepam was not administered as ordered after the 12 second seizure at 10:43am. Individual #1's seizure record logged 12 seizures on 1/16/19 occurring between 9:33am and 1:12pm. Between 9:33am and 10:56am, the individual had a 5 second, 11 second, 2-twelve second, 15 second, 10 second and 35 second seizures totally more than 5 seizures in any given day over 10 seconds. Per the individual's seizure protocol, the first doze of Diazepam should have been administered at 10:56 am after the 6th documented seizure of the day lasting over 10 seconds. The medication was not administered. Then staff recorded that the individual continued to have seizures, 12 seconds at 11:03am, 12 seconds at 12:19pm, 11 seconds at 12:56pm, 13 seconds at 1:10pm, and 11 seconds at 1:12 pm, throughout the day. According to the individual's doctor's ordered seizure protocol, the individual should have been administered a 2nd dose of Diazepam after her 11 second seizure at 12:56pm. Diazepam was not administered. According to the Individual's Individual Support Plan (ISP), it states that the individual has a seizure protocol in place. Per the individuals 8/9/18 and 8/11/17 physical examinations signed by the individual's physician, the seizure protocol is as follows: "give Diazepam 5mg for greater than 2 seizures lasting longer than 30 seconds in one hour (or for greater than 5 seizures lasting more than 10 seconds) in on day. max 3 doses in a 24 hour period." According to the individual's seizure log, staff recorded that the individual had multiple seizures on 12/21/18. The seizure details were recorded as followed: "5 minute seizure at 9:20am, 1 minute seizure at 9:26am, 1 minute and 9 second seizure at 9:30am, 2 minute and 3 second seizure at 9:35am, and 25 second seizure at 9:49am." According to the individuals medication administration record, diazepam was not administered on 12/21/18 until 9:55am, 25 minutes after it should have been administered per the doctor's order. According to the seizure log, Individual #1 had 6 seizures recorded on 12/26/18, however only 5 of them were over 10 seconds. According to the doctor's protocol, diazepam did not need to be administered. However it was administered on 2:13pm on 12/26/19. Individual #1 was administered Diazepam 5mg/ml at 9:25am and 10am on 12/27/18. According to her seizure record, she continued to have seizures from 11am to 1:22pm. According to her doctor's ordered seizure protocol, "If still having seizure activity after an additional 30 min, can give a 3rd dose and call 911 for patient to be evaluated in the ER." A third dose of Diazepam was never administered on 12/27/18. Per the incident reported by the agency and a staff note completed on 12/27/18, 911 was not contacted until 1:15pm on 12/27/18, 2 hours and 15 minutes after the doctor's order. (continued)This applies to abuse occurring at the facility. Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse. Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview As a result of this citation, UCP conducted an investigation with a certified investigator. The preliminary results of this investigation revealed that the medication was not given as per the protocol due to the individual either being in a seizure or being uncooperative during the medication administration process. The staff did not record this information accurately in the record/MAR. As a result the staff were retrained on the Seizure Protocol and proper documentation and accurate completion of the MAR. Moving forward all staff will be trained on seizure protocols and asked to follow verbatim or if unable to do so, to enter a note indicating the reasons why. In addition the Seizure record was moved to the front of the MAR to ensure easy access and review. The program specialist will review the MAR daily to ensure medications are administered as prescribed, if errors of omission are found EIM reports will be filed and a call placed to the individual's doctor for direction. The program Manager will review MARS monthly during her visits to ensure all medications are administered and recorded correctly. UCP will conduct quarterly audits to ensure compliance with this regulation. 08/31/2019 Implemented
2380.111(c)(4)Individual #1's 8/9/18 physical examination form did not include a vision or hearing screening. The doctor recorded on her physical examination forms that a vision and hearing screening was not recommended and "impossible due to MR (Mental Retardation)." The individual's intellectual disability it not an appropriate reason for not performing medical tests per the department's interpretation.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The Program Specialist has been retrained on 2380.111(c)(4). (Attachment # 6) Individual #1¿s Annual Physical has been updated (Attachment # 16 ) The Program Specialist will ensure all pertinent sections of the Annual Physical exam are completed including vision and hearing screenings as shown in the Annual Exam for CS. (Attachment # 17) The Program Manager will check physicals monthly during her visits to ensure compliance. UCP will do Quarterly audits of individual records with agency-approved audit worksheets to ensure compliance in this area. (Attachment # A ) 08/31/2019 Implemented
2380.111(c)(7)Individual #2's 9/13/18 physical examination form did not include an assessment of the individual's health maintenance needs. This section is left blank on the physical form.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The Program Specialist has been retrained on 2380.111(c)(7). (Attachment # 5) Individual #1¿s Annual Physical has been updated (Attachment # 16 ) The Program Specialist will ensure all pertinent sections of the Annual Physical exam are completed including the assessment of individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals as shown in the Annual Exam for CS. (Attachment # 17) The program manager will check physicals on a monthly basis to ensure compliance with this regulation. IN addition UCP will conduct quarterly audits of individual records to ensure compliance to all regulations with agency-approved audit worksheets to ensure compliance in this area. (Attachment #A ) 08/31/2019 Implemented
2380.111(c)(10)REPEAT from 6/29/18 annual inspection: Individual #1's 8/9/18 physical examination form and Individual #2's 9/13/18 physical examination form did not include a completed section to identify the individual's "information pertinent to diagnosis and treatment in case of an emergency." This field was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Program Specialist has been retrained on 2380.111(c)(10). (Attachment # 7) Individual #1¿s Annual Physical has been updated (Attachment # 16) The Program Specialist will ensure all pertinent sections of the Annual Physical exam are completed including the medical information pertinent to diagnosis and treatment in case of an emergency as shown in the Annual Exam for CS. (Attachment # 17) The program manager will conduct monthly reviews of the physicals. UCP will also conduct quarterly audits of the program to ensure compliance with this regulations. (see attachment #A) ¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment # ) 08/31/2019 Implemented
2380.111(c)(11)Individual #1's 8/9/18 physical examination form did not include their specific dietary recommendations/needs. The doctor recorded on the form that there were no recommended diet and special instruction. However the doctor signed the lifetime medical history document attached to the 8/9/18 physical examination. In the lifetime medical history document, it was recorded that the individual had a "staff person near to monitor for any signs of choking. Staff offers the individual smaller portions in small containers to limit the risk of shoveling," and "it has been noted and observed in the past, she has a shoveling technique while eating." The form also recorded a diagnosis of "Esophagitis (inflammation of food pipe and stomach)." According to the individual's 8/11/17 physical examination form, someone with the initial's JR recorded under the section for "special instructions for diet: assistance with cutting food into bite seize pieces, choking risk, should not eat sweets 4/2/18."The physical examination shall include: Special instructions for an individual's diet.The Program Specialist has been retrained on 2380.111(c)(11). (Attachment # 8) Individual #1¿s Annual Physical has been updated (Attachment # 16 ) to reflect dietary restrictions. IT is the Program Specialist role to ensure all pertinent sections of the Annual Physical exam are completed including the dietary recommendations as shown in the Annual Exam for CS. (Attachment # 17 ) The Program Manager will review individual files on a monthly basis. In addition Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment # A ) 08/31/2019 Implemented
2380.121(d)Individual #1's Diazepam solution medication bottle and dropper were stored in a cloth and plastic, zippered, old, pencil pouch. There was also a piece of paper towel crumbled up in the pouch. The dropper that goes in the individual's mouth was not covered or protected from contamination.Prescription and nonprescription medications shall be stored under proper conditions of sanitation, temperature, moisture and light.The Program Specialist was retrained on 2380.121(e). (Attachment # 3) The Expired medication was returned to the residential provider on 6-19-19 and new medication was brought into Lewistown CPS. (Attachment # 13 ) The Program Specialist will ensure that any discontinued or expired medications are returned to the family or residential facility using the attached form. (Attachment # 14 )The program manager will review all medications on a monthly basis to ensure they are stored properly. In addition Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment # A ) 08/31/2019 Implemented
2380.121(e)Individual #1 is prescribed "Ondansetron 4mg tablet, dissolve 1 tablet on tongue every 8 hours as needed for nausea. May crush and administer in liquid or applesauce" by their physician. According to the medication label available at the day program, the medication expired in April 2019 and there wasn't another medication available for the individual at the day program. The medication is expired and wasn't returned to the residential program for proper disposal.Discontinued prescription medications shall be returned to the individual¿s family or residential program for proper disposal.The Program Specialist was retrained on 2380.121(e). (Attachment # 3) The Expired medication was returned to the residential provider on 6-19-19 and new medication was brought into Lewistown CPS. (Attachment # 13 ) The Program Specialist will ensure that any discontinued or expired medications are returned to the family or residential facility using the attached form. (Attachment # 14 ) The program manager will review all medications on a monthly basis to ensure none are expired. In addition UCP will conduct Quarterly audits of individual records within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment # ) 08/31/2019 Implemented
2380.181(e)(5)Individual #2's current, 7/9/18 assessment does not assess his ability to self-administer medications. The individual current takes an allergy medication as an as needed medication.The assessment must include the following information: The individual¿s ability to self-administer medications.The Program Specialist was retrained on 2380.181(e)(5). (Attachment # 2) individual #2¿s assessment dated 7/9/18 has been updated via addendum dated 7/1/19 to include their ability to self-administer medications. (Attachment # 11) The Program Specialist and Manager CPS will ensure that assessments are completed with documentation of the individual's ability to self-administer medications as evidenced by the attached assessment for BM dated 7/5/19. (Attachment # 12 ) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment # A ) 08/31/2019 Implemented
2380.185(b)Individual #1 is prescribed "Ondansetron 4mg tablet, dissolve 1 tablet on tongue every 8 hours as needed for nausea. May crush and administer in liquid or applesauce" by their physician since at least April of 2018. According to the medication available at the day program during the 6/18/19 annual inspection , the medication expired in April 2019. There wasn't another medication available for Individual #1 at the day program. According to the Individual's Individual Support Plan (ISP), it states that the individual has a seizure protocol in place. Per the individuals 8/9/18 and 8/11/17 physical examinations signed by the individual's physician, the seizure protocol is as follows: "give Diazepam 5mg for greater than 2 seizures lasting longer than 30 seconds in one hour (or for greater than 5 seizures lasting more than 10 seconds) in on day. max 3 doses in a 24 hour period." According to the individual's seizure log, staff recorded that the individual had multiple seizures on 12/21/18. The seizure details were recorded as followed: "5 minute seizure at 9:20am, 1 minute seizure at 9:26am, 1 minute and 9 second seizure at 9:30am, 2 minute and 3 second seizure at 9:35am, and 25 second seizure at 9:49am." According to the individuals medication administration record, diazepam was not administered on 12/21/18 until 9:55am, 25 minutes after it should have been administered per the doctor's order.The ISP shall be implemented as written.The Program Specialist and Coordinators have been retrained on 2380.185(b) (Attachment # 1) All staff have been retrained on Individual #1¿s Seizure Protocol (Attachment # 10 ) Moving forward the Program Specialist will be responsible for ensuring that protocols are followed as directed. The Program Manger will review individual files monthly to ensure compliance with this regulation. In addition UCP will conduct quarterly audits to ensure compliance with this regulation. (see attachment A) 07/24/2019 Implemented
2380.126(d)(continued from previous violation page) The individual's seizure log documented that she continued to have 33 documented seizures on 12/28/19 at program. From 8:16am-8:31am she had more than 5 seizures lasting over 10 seconds long. Her Diazepam was administered at 8:36am. However, staff documented that the individual continued to have seizures 30 minutes after her first dose of Diazepam. Her second dose of Diazepam was not administered until 10:35am even though it should have been administered at 9:10am; 30 minutes after her dose of Diazepam and still having seizures. According to her seizure logs, she was still seizing 30 minutes after her 2nd dose of Diazepam. A 3rd dose of Diazepam was never administered and 911 was never called. Individual #1 had documented 33 seizures throughout the entire day on 12/28/18 and medical attention was never sought. This occurred less than one day after the individual was hospitalized due to an increased number and length of seizures at the day program the previous day. The agency did not have documentation of follow up action or medical discharge instructions to follow after the individual was hospitalized on 12/27/18.The directions of the prescriber shall be followed.UCP is conducting an investigation into this matter to determine why the Diazepam was not administered in accordance with the PC's seizure protocol. All staff were retrained on the individuals most recent seizure protocol. The Program Specialist will ensure that the most current Protocols are in place for all individuals and staff are trained on said Protocols. The program manager will monitor each individual with protocols on a monthly basis to ensure no errors are made. In addition, Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (see attachment A) 08/31/2019 Implemented
2380.126(d)Individual #1's Diazepam medication label and 12/31/18 doctor ordered seizure protocol stated to "administer 5mg (1ml) for greater than 2 seizures lasting longer than 30 sec in one hr (or for greater than 5 seizures (lasting more than 10 sec) in one day." The individual's 12/31/18 doctor's ordered seizure protocol indicates, " If still having seizure activity after 30 min can give another dose. If still having seizure activity after an additional 30 min, can give a 3rd dose and call 911 for patient to be evaluated in the ER." According to the individual's seizure log for 4/5/19, it was documented that the individual had 10 documented seizures from 8:25am to 10:50am lasting anywhere from 8 seconds to 30seconds. Six seizures lasting more than 10 seconds occurred from 8:25am until 9:28am. Diazepam was not administered until 10:55am, over an hour after the doctor's order. Then, the individual's seizure log stated that the individual continued to have seizures at 9:31am, 10:43am and 10:55am. An additional dose of Diazepam was not administered as ordered after the 12 second seizure at 10:43am. Individual #1's seizure record logged 12 seizures on 1/16/19 occurring between 9:33am and 1:12pm. Between 9:33am and 10:56am, the individual had a 5 second, 11 second, 2-twelve second, 15 second, 10 second and 35 second seizures totally more than 5 seizures in any given day over 10 seconds. Per the individual's seizure protocol, the first doze of Diazepam should have been administered at 10:56 am after the 6th documented seizure of the day lasting over 10 seconds. The medication was not administered. Then staff recorded that the individual continued to have seizures, 12 seconds at 11:03am, 12 seconds at 12:19pm, 11 seconds at 12:56pm, 13 seconds at 1:10pm, and 11 seconds at 1:12 pm, throughout the day. According to the individual's doctor's ordered seizure protocol, the individual should have been administered a 2nd dose of Diazepam after her 11 second seizure at 12:56pm. Diazepam was not administered. According to the Individual's Individual Support Plan (ISP), it states that the individual has a seizure protocol in place. Per the individuals 8/9/18 and 8/11/17 physical examinations signed by the individual's physician, the seizure protocol is as follows: "give Diazepam 5mg for greater than 2 seizures lasting longer than 30 seconds in one hour (or for greater than 5 seizures lasting more than 10 seconds) in on day. max 3 doses in a 24 hour period." According to the individual's seizure log, staff recorded that the individual had multiple seizures on 12/21/18. The seizure details were recorded as followed: "5 minute seizure at 9:20am, 1 minute seizure at 9:26am, 1 minute and 9 second seizure at 9:30am, 2 minute and 3 second seizure at 9:35am, and 25 second seizure at 9:49am." According to the individuals medication administration record, diazepam was not administered on 12/21/18 until 9:55am, 25 minutes after it should have been administered per the doctor's order. According to the seizure log, Individual #1 had 6 seizures recorded on 12/26/18, however only 5 of them were over 10 seconds. According to the doctor's protocol, diazepam did not need to be administered. However it was administered on 2:13pm on 12/26/19. Individual #1 was administered Diazepam 5mg/ml at 9:25am and 10am on 12/27/18. According to her seizure record, she continued to have seizures from 11am to 1:22pm. According to her doctor's ordered seizure protocol, "If still having seizure activity after an additional 30 min, can give a 3rd dose and call 911 for patient to be evaluated in the ER." A third dose of Diazepam was never administered on 12/27/18. Per the incident reported by the agency and a staff note completed on 12/27/18, 911 was not contacted until 1:15pm on 12/27/18, 2 hours and 15 minutes after the doctor's order. (continued on next page)The directions of the prescriber shall be followed.UCP is conducting an investigation into this matter to determine why the Diazepam was not administered in accordance with the PC's seizure protocol. All staff were retrained on the individuals most recent seizure protocol. The Program Specialist will ensure that the most current Protocols are in place for all individuals and staff are trained on said Protocols. The program manager will monitor each individual with protocols on a monthly basis to ensure no errors are made. In addition,Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (see attachment A) 08/31/2019 Implemented
SIN-00136376 Renewal 06/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual # 1's 06/18/18 physical did not contain information pertinent to diagnosis and treatment in case of an emergency. Space left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.¿ Program Specialist was retrained on 55 PA Code Chapter 2380.111(c)(10) (Attachment #1) ¿ Individual #1¿s physical exam was completed in the area of medical information pertinent to diagnosis and treatment in case of an emergency. (Attachment #2) ¿ Program Supervisor has ensured that the section addressing medical information pertinent to diagnosis and treatment in case of an emergency is completed on physical examinations received for each individual attending the program. (Attachment #3) ¿ Program Specialist will complete initial review of all physicals as they are received for thoroughness and accuracy as per the ISP. ¿ Program Specialist will forward the physical to the Program Manager for review of compliance with regulatory expectations. ¿ Physical letter notices sent to providers/caregivers will specify the requirement that all sections of the physical exam are relevant and necessary to documenting and assessing the individual¿s ongoing health and must be filled out in complete form for acceptance by the program. (Attachment #4) ¿ Quarterly audit of individual records will be completed with the program with agency audit worksheets to ensure compliance in this area. (Attachment #14) 07/18/2018 Implemented
2380.181(e)(7)Individual # 2's 03/16/18 assessment did not assess 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 was retrained in 55 PA Code Chapter 2380.181(e) (7). (Attachment #5) ¿ An Addendum to Individual #2s Assessment dated 3/6/2018 was completed on 7/18/18 by Program Specialist to include documentation of individual¿s ability to sense and move away from heat sources quickly. (Attachment #6) ¿ Program Specialist and Manager of Adult Day Services will ensure that assessments are completed with documentation of the individual's understanding of the danger of heat sources and ability to sense and move away from heat sources quickly using the attached tool (Attachment #13) ¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #14) 07/18/2018 Implemented
2380.183(3)Individual # 1 and Indivdiual # 2's ISP(s) did not contain a measureable outcome. Outcome describes what staff are to do but no measurable pieces to determine outcome progress.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.¿ Program Specialist was retrained in 55 PA Code Chapter 2380.183(3). (Attachment #7) ¿ Program Specialist will create Outcomes Plan for individuals and send to the SC to be entered into the ISP. (Attachment #8 & 9 ) ¿ Program Specialist will ensure that all outcomes are measurable using the attached tool. (Attachment #13 ¿ Quarterly audit of individual records will be completed with the program with agency audit worksheets to ensure compliance in this area. (Attachment #14) 07/18/2018 Implemented
2380.186(c)(2)Indivdiual # 2's 04/25/18 ISP review describes SEEN plan however does not indicate SEEN plan utilization. Fall and seizure protocols not reviewed as well as GERD, Supraventricular tachychardia. Individual # 1's 11/08/17, 02/06/18 and 05/04/18 reviews do not include fall protocol updates.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.¿ Program Specialist was retrained in 55 PA Code Chapter 2380.186(c) (2). (Attachment #10) ¿ An addendum to the 3 month review dated 5/4/18 was completed on 7/18/18 by Program Specialist to reflect the review of the social, emotional, environmental needs plan. (Attachment #11) ¿ ISP Reviews will be completed to include a review of each section of the ISP, including the social, emotional, environmental needs plan as evidenced by CG¿s Quarterly Review dated (Attachment #12) ¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #14) 07/21/2018 Implemented
SIN-00111427 Renewal 06/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The poisonous materials where kept under the sink located in the main program area. There was two hinges with a lock in the middle, but the inspector was able to open the cabinet doors and reach in and take out the poisons one by one. The posions, where not inaccessible to Individuals. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.It is important that poisonous materials are securely locked and that no person be able to reach in and take out the poisons. The Program Specialist has been trained on the importance of securing poisonous materials for the health and safety of the individuals. The locks that were utilized during the licensing have been removed and replaced with locks that are more secure. The locks recently installed on the cabinets are secure and prevent anyone from accessing poisonous materials without a key. Attachment 53 A is a photo of the new locks that were installed on all cabinets that hold poisonous materials throughout the program. Attachment ? is a list of topics that will be discussed during a staff training in regards to the plan of correction. Attachment ? is a tracking sheet that will be used by the Program Manager during quarterly oversights. 10/16/2017 Implemented
2380.89(e)The agency was only using 1 exit for fire drills. There are an additional 2 exits that could be used during a fire drill. Alternate exit routes shall be used during fire drills.It is important that the agency uses a primary and secondary exit during routine fire drills. The Program Specialist has been trained on the importance of utilizing more than one exit during monthly fire drills. The Program Specialist will start rotating exits with individuals and staff members during evacuation of fire drills A fire drill has been performed since the date of licensing using a secondary exit. The Program Specialist will submit completed fire drill forms to the Executive Assistant of the agency upon completion of each drill. Attachment 89 E is a copy of the most recent fire drill conducted using the secondary exit out of the program. Attachment ? is a list of all topics that will be discussed during a staff training about the plan of correction. Attachment ? is a tracking sheet that will be used by the Program Manager during the quarterly oversights. 10/16/2017 Implemented
2380.111(b)The physical exam for Individual #2 was not dated by the licensed physician. The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.It is important the an individual¿s physical exam be dated by the licensed physician. The Program Specialist has been trained and will review each individual physical to ensure that it has been dated by the licensed physician. Attachment 111 B is a current physical of another individual that is compliant and dated by the physician. The Program Specialist will begin to review each physical upon receipt to maintain future compliance. A staff training will be held to cover a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ? is a tracking sheet that will be used by the Program Manager during oversight each quarter. 10/16/2017 Implemented
2380.111(c)(5)Repeat from 2016- Physical exam for Individual #2 did not have a TB test prior to attending the program. Date of Attendance 2-22-17, TB completed 3-3-17. 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.It is important that physical exams for individuals have a TB test prior to attending the program. The Program Specialist has been trained and will review each individual¿s physical to ensure that the licensed physician has documented a TB test. If the physical does not include a current TB test the individual will not be able to attend until the TB is completed and physical is again reviewed by the Program Specialist. Attachment 111 C 5 is a current physical of another individual that is in compliance. A staff training will be held discussing a variety of topics for the plan of correction. Attachment ? includes a list that will be discussed at the training. Attachment ? is a tracking sheet that will be utilized be the Program Manager during the oversight each quarter. 10/16/2017 Implemented
2380.111(c)(6)Individual #2 annual physical did not include if free from communicable disease. This section was left blank.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.It is important that physical exams include that the individual is free from communicable diseases. The Program Specialist has been trained and will review each individual¿s physical to confirm that the licensed physician has noted that he or she is free of communicable diseases. If the physical does not reflect that the individual is indeed free of communicable diseases he or she will not be able to attend program until it is clearly stated by the physician. Attachment 111 C 6 is a current physical of another individual that is in compliance and states that the individual is free of communicable diseases. Attachment ? is a list of topics that will be discussed at the staff training. Attachment ? is a tracking sheet that will be used by the Program Manager during the quarterly oversight. 10/16/2017 Implemented
2380.111(c)(7)Individual #2's physical exam did not assess the health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.It is important that the annual physical exam assess the health maintenance needs, medication regimen, and the need for blood work at recommended intervals. The Program Specialist has been trained on the importance of ensuring that the health maintenance section is completed by the licensed physician. If the physical is not completed a request will be made to the care givers, families, and physician requesting the missing information be completed by the licensed physician. Attachment 111 C 7 is a completed physical that is compliance where the physician has completed the section titled health maintenance needs. Attachment ? is a list of topics related to the plan of correction that will be discussed during a staff training. Attachment ? is a tracking sheet that will utilized by the Program Manager during the quarterly oversight. 10/16/2017 Implemented
2380.111(c)(11)Individual #2's diet section was left blank on the physical exam form.The physical examination shall include: Special instructions for an individual's diet.It is important that the diet section of the annual physical exam be completed. The Program Specialist has been trained on the importance of ensuring the diet section of each physical be completed. If the diet section of the physical has not been completed the Program Specialist will request that the family and caregivers request that the physician complete the physical in its entirety. The Program Specialist will also send a request along with a copy of the physical to the licensed physician asking that he or she complete the diet section. Attachment 111 C 11 is a current physical of another individual that is in compliance where the physician has completed the diet section. Attachment ? is a list of topics that will be discussed during a staff training on the plan of correction. Attachment ? is a tracking sheet that will be used by the Program Manager during the quarterly oversight. 10/16/2017 Implemented
2380.113(a)Repeat Violation 2016- Staff person #1 physical exam was not every 2 years, it was late- 2/11/15-2/27/17. Staff person #2 phyiscal was late 1/15/14-6/27/16.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.It is important that each staff member complete all staff physical exams biannually. The Program Specialist has been trained and will keep a written record of all staff physicals ensuring they are completed within the designated time. If the physical is not completed within the assigned timeframe, the staff member will be removed from the weekly schedule until it is completed in its entirety. Attachment 113 A is a list of all staff members and the date each staff¿s physical will be due. A staff training will be held covering a summary of topics concerning the plan of correction. In addition, attachment ? is a tracking sheet that will be used by the Program Manager each quarter during the oversight. 10/16/2017 Implemented
2380.154(d)Individual #1 had a restrictive plan in place, but there was no record of meetings of the restrictive review committee. There was no restrictive committee reviewing the plan in place. A written record of the meetings and activities of the restrictive procedure review committee shall be kept.It is important that records of the meetings be maintained for individuals who have a restrictive plan. The Program Specialist has been trained and will keep a written record of meetings and activities of the restrictive procedure review committee. Attachment 154 A is the invitation to the critical revision that was held for the individual. At the critical revision it was discussed the need for a restrictive plan is no longer necessary and a SEEN plan will used in its place. If a concern arises, a critical revision will be scheduled to discuss a behavior support plan that will be developed by a Behavior Support Specialist that is referred by the Supports Coordinator. A staff training will be held covering a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ? is a tracking sheet that will be used by the Program Manager each quarter during the oversight. 10/16/2017 Implemented
2380.155(a)The restrictive plan for Individual #1 was not completed yearly. 3/29/16- 6/12/17. These plan where not written prior to the use of the restrictive proceedures. For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to the use of restrictive procedures.It is important that a restrictive plan be written prior to the use of restrictive procedures. The Program Specialist has been trained and will ensure that restrictive plans be reviewed before implementing the restrictive plan. Attachment 155 A, 155 D, 154 D, includes the invitation letter to the critical revision and signature sheet from the meeting. The current restrictive plan was discussed among the team and has been decided that the restrictive plan will be removed from the ISP. In place of the restrictive plan a SEEN plan will be utilized until an aggressive behavior were to occur. At that time, a critical revision will be scheduled to discuss the need of a restrictive plan. A staff training will be held covering a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ?, is a tracking sheet that will be utilized by the Program Manager each quarter during the oversight. 10/16/2017 Implemented
2380.155(d)The restrictive proceedure plan for Individual #1, was not reviewed, approved by a chair person, or a restrictive committee, prior to the use of the restrictive plan. The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.It is important that a restrictive procedure plan be reviewed, approved by a chairperson, or a restrictive committee, prior to the use of the restrictive plan. The Program Specialist has been trained and will ensure that a restrictive plan is reviewed, approved by a chairperson, or a restrictive committee, prior to the use of any restrictive plan for an individual. Attachment 155 A, 155 D, and 154 D includes the invitation letter to the critical revision and signature sheet from the meeting. The current restrictive plan has been discussed with all team members and it was agreed that the restrictive plan be removed from the individual¿s ISP. The program will utilize a SEEN plan in its place until a need for a behavior plan arises. If this occurs, the Supports Coordinator will request a Behavior Support Specialist for the individual. A staff training will be held covering a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ? is a tracking sheet that will be used by the Program Manager each quarter during the oversight. 10/16/2017 Implemented
2380.173(7)Individual #1 & #2's record did not contain the most current copy of the ISP. Current Copies of the ISP where asked for while conducting the inspection. Each individual¿s record must include the following information:  A copy of the current ISP.It is important that each individual¿s record contain the most current ISP. The Program Specialist has been trained and will ensure that each individual record contain the most recent copy of his or her ISP. The Program Supervisor will review each individual record monthly to ensure that ISP¿s are current to maintain future compliance. Attachment 173 C is the most recent ISP available through HCSIS for another individual. A staff training will be held covering a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ? is a tracking sheet that will be utilized by the program Manager each quarter during oversight. 10/16/2017 Implemented
2380.181(e)(12)Individual #1 and Individual #2's annual assessments were missing the section- Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.It is important that each Annual Assessment include recommendations for specific areas of training, vocational programming, and competitive community integrated employment. The Program Specialist has been trained on a revised Annual Assessment format. The Program Specialist will ensure that the Annual Assessment is completed in its entirety at the Annual Assessment due date. The Program Manager will inspect the Annual Assessments each quarter to ensure that the specific areas are included in each assessment. Attachment 181 E 12 is the most recent Annual Assessment for another individual that was completed on June 29, 2017 by the Program Specialist. A staff training will be held covering a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ?, is a tracking sheet that will be utilized by the Program Manager each quarter during oversight. 10/16/2017 Implemented
2380.181(f)The 11/23/16 assessment for Individual #1 and the 3/22/17 assessment for Individual #2- there was no record that the annual assessments where sent to the team members. The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).It is important that the Program Specialist disburse the Annual Assessment to the Supports Coordinator and team members at least thirty calendar days prior to an ISP meeting for the development, annual update, and revision of the ISP. The Program Specialist has been trained and will ensure that a disbursement letter will be sent along with each annual assessment that is disbursed to the Supports Coordinator and team members thirty calendar days prior to the ISP meeting in order to maintain future compliance. Annual Assessments and disbursement letters completed by the Program Supervisor will be reviewed every quarter to ensure both were distributed to all team members. Attachment 181 F is the most recent Annual Assessment Disbursement letter for another individual that was completed on July 03, 2017 by the Program Specialist. A staff training will be held covering a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ?, is a tracking sheet that will be utilized by the Program Manager each quarter during oversight. 10/16/2017 Implemented
2380.186(b)The ISP reviews for Individual #1 & #2 where not dated by the program specialist. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.It is important that the date be included next to the signature of the individual and Program Specialist on the ISP Review. Attachment 186 B is the most recent review of another individual where the Program Specialist has made the change to an ISP Review that was completed after licensing. The Program Specialist has been trained on a new ISP Review format in order to maintain future compliance. The Program Specialist will ensure the form is completed, signed, and dated on each ISP/Quarterly that is reviewed with the individual. The Program Manager will inspect the ISP Reviews completed by the Program Specialist each quarter to ensure compliance. The Program Manager trained the Program Specialist on the new ISP Review format on June 27, 2017. A staff training will be held covering a summary of topics for the plan of correction. In addition attachment ? includes a list of topics that will be discussed at the training. Attachment ?, is a tracking sheet that will be utilized by the Program Manager each quarter during oversight. 10/16/2017 Implemented
2380.186(e)The option for decline for Individual #1 was not sent to all team members. The residential supervisor was not given the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.It is important that each Option to Decline Letter be disbursed to current team members of each individual. The Program Specialist has been trained on the importance of updating all contact information of each team member and which Residential Supervisor is assigned to each individual. Program Specialist will ensure that each Option to Decline letter include the current team members. The Program Manager will inspect the Option to Decline letters each quarter to ensure that the team members listed are the most current assigned to each individual. Attachment 186 E is the most recent Option to Decline Letter of another individual completed by the Program Specialist on July 03, 2017 after the date of licensing. A staff training will be held covering a summary of topics for the plan of correction. In addition, attachment ? includes a list of topics that will be discussed at the training. Attachment ?, is a tracking sheet that will be utilized by the Program Manager each quarter during oversight. 10/16/2017 Implemented
SIN-00101907 Unannounced Monitoring 10/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The water temperature in the new program area bathroom was tested to be 103F. This exceeded the 120F. Hot water temperatures in areas accessible to individuals may not exceed 120°F.The landlord was contacted and Johnson's Plumbing & Heating regulated the water temperature to 115 degrees. 10/10/2016 Implemented
SIN-00094648 Renewal 05/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(e)Staff #2 had fire safety on 1/22/13 and then 9/2/14. Their hire date was 12/22/03. Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The Program Specialist will be responsible for tracking individual training hours and fire safety trainings. Several trainings will be scheduled throughout the year to ensure all staff will have an opportunity to attend. A record of all trainings will be kept by the Program Specialist. The Assistant Director of Adult Services will review training records biannually to ensure ongoing compliance. See Attachment J. 06/03/2016 Implemented
2380.58(a)The counter drawer beside the fridge was missing a hande. Floors, walls, ceilings and other surfaces shall be in good repair.The missing handle was replaced. The Program Specialist will be responsible for inspecting the program site weekly and reporting any concerns or need for repairs to the Assistant Director of the maintenance department. See Attachment I 06/03/2016 Implemented
2380.70(e)There was no first aide manual with the first aid kit. A first aid manual shall be kept with each first aid kit.A first aide manual was purchased and added to the first aide kit. The first aide treatment cards contained in the kit will no longer be considered a manual. The Program Specialist will review first aide kit contents monthly to ensure ongoing compliance.See Attachment H 06/03/2016 Implemented
2380.111(c)(1)Individual #2 physical dated 4/13/16 did not have immunizations listed. The physical examination shall include: A review of previous medical history.A review of individual physicals was conducted by the Program Specialist and reviewed by the Assistant Director of Adult Services and any concerns resolved. The Program Specialist will be responsible for reviewing all incoming individual examinations for thoroughness and accuracy. An incomplete exam, or one found to contain incorrect information, will be returned to the physician for correction. A copy of the correspondence will be kept in the individual file. The Assistant Director of Adult Services will review a sampling of files quarterly to ensure ongoing compliance. See Attachment G 06/03/2016 Implemented
2380.111(c)(4)Individual #2's physical dated 3/13/16 did not contain vision and hearing screening. The physical examination shall include: Vision and hearing screening, as recommended by the physician.A review of individual physicals was conducted by the Program Specialist and reviewed by the Assistant Director of Adult Services and any concerns resolved. The Program Specialist will be responsible for reviewing all incoming individual examinations for thoroughness and accuracy. An incomplete exam, or one found to contain incorrect information, will be returned to the physician for correction. A copy of the correspondence will be kept in the individual file. The Assistant Director of Adult Services will review a sampling of files quarterly to ensure ongoing compliance.See Attachment G 06/03/2016 Implemented
2380.111(c)(5)Individual #2's physical dated 4/13/16 did not have tuberculin skin testing listed. 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.A review of individual physicals was conducted by the Program Specialist and reviewed by the Assistant Director of Adult Services and any concerns resolved. The Program Specialist will be responsible for reviewing all incoming individual examinations for thoroughness and accuracy. An incomplete exam, or one found to contain incorrect information, will be returned to the physician for correction. A copy of the correspondence will be kept in the individual file. The Assistant Director of Adult Services will review a sampling of files quarterly to ensure ongoing compliance.See Attachment G 06/03/2016 Implemented
2380.111(c)(9)Individual #2's physical dated 4/13/16 stated NKA and the ISP stated allergies to corn, aspirin, mantoux, and metformin. The physical examination shall include: Allergies or contraindicated medication.A review of individual physicals was conducted by the Program Specialist and reviewed by the Assistant Director of Adult Services and any concerns resolved. The Program Specialist will be responsible for reviewing all incoming individual examinations for thoroughness and accuracy. An incomplete exam, or one found to contain incorrect information, will be returned to the physician for correction. A copy of the correspondence will be kept in the individual file. The Assistant Director of Adult Services will review a sampling of files quarterly to ensure ongoing compliance.See Attachment G 06/03/2016 Implemented
2380.113(a)Staff #2 had a physcial dated 12/11/13 and there was no other physical in the record. 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.The Program Specialist will be responsible for ensuring all staff have physical exams in a timely manner. The Assistant Director and Program Specialist will utilize a tracking sheet to ensure all staff receive prompting to complete their biennial physicals.The Assistant Director will review a sampling of staff files biannually to ensure ongoing compliance. See Attachment F 06/03/2016 Implemented
2380.173(1)(v)Individual #2 did not have a dated photo in the record. Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Regulation 2380.173 was reviewed with the Program Specialist by the Assistant Director of Adult Services. A review of Individual files was conducted to correct and discrepancies. The Program Specialist will be responsible for ensuring all required personal information is contained in the individual file and updated as necessary. The Assistant Director of Adult Services will review a sampling of files quarterly to ensure ongoing compliance. See Attachment E 06/03/2016 Implemented
2380.173(9)Individual #1's physcial states allergies to keflex and ISP states only seasonal allergies. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Regulation 2380.173 was reviewed with the Program Specialist by the Assistant Director of Adult Services. A review of Individual files was conducted to correct and discrepancies. The Program Specialist will be responsible for ensuring all required personal information is contained in the individual file and updated as necessary. The Assistant Director of Adult Services will review a sampling of files quarterly to ensure ongoing compliance. See Attachment E 06/03/2016 Implemented
2380.181(e)(13)(i)Individual #1's assessment did not contain progress over the last 365 calandar days and current level in health. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Program Specialist will be responsible for ensuring that individual progress and growth over the previous year is contained in the Individual Assessment. The areas of growth will be documented throughout the assessment and summarized on the Progress and Growth addendum. The Assistant Director will review files quarterly to ensure ongoing compliance. See Attachment C 06/03/2016 Implemented
2380.181(e)(13)(v)Individual #1's assessment did not contain progress over the last 365 calandar days and current level in recreation. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Program Specialist will be responsible for ensuring that individual progress and growth over the previous year is contained in the Individual Assessment. The areas of growth will be documented throughout the assessment and summarized on the Progress and Growth addendum. The Assistant Director will review files quarterly to ensure ongoing compliance. See Attachment C 06/03/2016 Implemented
2380.181(f)Individual #1's assessment did not contain who it was sent too or when it was sent.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The Program Specialist will be responsible for ensuring the assessment is received by all team members at least 30 days prior to the ISP meeting. A copy of the companion letter noting to whom the assessment was sent will be kept in the file alongside the assessment. The Assistant Director of Adult Services will review individual files quarterly to ensure ongoing compliance. See Attachment D 06/03/2016 Implemented
2380.185(a)Individual #1 had ISP meeting on 8/11/15 and was not implemented until 11/17/15.The ISP shall be implemented by the ISP's start date.Regulation 2380.185 was reviewed with the Program Specialist by the Assistant Director of Adult Services. The Program Specialist will be responsible for ensuring the ISP is implemented by the ISP start date. The Program Specialist will notify the individual's supports coordinator via email of the need for an approved plan if no notice of such has been received within 5 working days of the ISP start date. See Attachment B. 06/03/2016 Implemented
2380.186(a)Individual #1's ISP reviews dated 5/12/16 and 11/11/15 did not cover the 3 month period. 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.Regulation 2380.186 was reviewed with the Program Specialist by the Assistant Director of Adult Services. The Program Specialist will be responsible for completing all ISP Reviews in a timely manner. The Assistant Director of Adult Services will be responsible for reviewing Individual Files quarterly to ensure ongoing compliance. See Attachment A 06/03/2016 Implemented
SIN-00074477 Renewal 03/05/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The wall behind the sink & behind toliet in the restroom off the kitchen area has wall board that is flacking and peeling paint.Floors, walls, ceilings and other surfaces shall be in good repair.A backsplash area was installed in the bathroom. The Program Site was inspected by the Program Supervisor for any needed repairs and none were noted. Program Specialist will review the program monthly and submit need for repairs on the monthly program report. Assistant Director of Adult Services will schedule repairs with the maintenance department. 04/01/2015 Implemented
2380.173(1)(ii)Individual #2's record did not include the following personal information: Height, weight, ID marks and religion. Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.All individual records were reviewed by the Program Specialist for completeness and accuracy. Individual #2's file was corrected. Program Specialist will be responsible for reviewing individual files quarterly and correcting any discrepancies. 04/01/2015 Implemented
2380.181(e)(13)(i)The annual assessment 5/1/14 for Individual #1 was missing progress and growth health, motor & communication, socialization, recreation and community intergration. The assessment must include the following information: The individuals progress over the last 365 calendar days and current level in the following areas: Health.Regulation 181 was reviewed with he Program Specialist by the Assistant Director of Adult Services. Individual files were reviewed for accuracy and completeness. Program Specialist will be responsible for ensuring individual progress over the previous year is included in the assessment. The Assistant Director of Adult Services will review random individual files quarterly to ensure compliance. 04/01/2015 Implemented
2380.186(d)There was no documentation for Individual #1 & #2 to tell if the Program Specialist sent the ISP reviews to all team members within 30 days after the ISP meeting. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Regulation 186(d) was reviewed with the Program Specialist by the Assistant Director of Adult Services. All individual files were reviewed and any discrepancies were corrected. The Program Specialist will be responsible for ensuring all ISP reviews are sent to the team members within 30 days after the meeting. Assistant Director of Adult Services will review files quarterly to ensure compliance. See Attachments A & B. 04/01/2015 Implemented
SIN-00061928 Renewal 03/18/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(c)(1)The ISP reviews for Individual #2 held on 12/31/13, 9/7/13, 6/18/13 and 3/19/13 did not include the SEEN/Behavioral management plan. The ISP stated that Individual #2 has a SEEN plan that was developed and implemented.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.Regulation 2380.186 was reviewed witht he Program Specialist by the Assistant Director of Adult Services. Program Specialist will be responsible for ensuring ISP Reviews contain updates and reviews regarding Behavior Support Plans when applicable.See Attachments A & B 03/26/2014 Implemented
SIN-00046798 Renewal 03/04/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)There was no documentation of a fire drill held in September 2012. (a)  An unannounced fire drill shall be held at least once a month.Regulation 2380.89 was reviewed with the Program Supervisor by the Assistant Director of Adult Services. Program Partially Implimented/Adequate Progress CSS 4-12-13 Supervisor will be responsible for ensuring fire drills are completed as required. Fire Drills will be monitored by the Assistant Director of Adult Services. Program Supervisor will complete fire drills at least 5 days prior to the end of the month and inform Assistant Director of the results via email. See Attachment A. 03/15/2013 Implemented
2380.91(a)Individual #1's fire safety training was not held annually. 7/28/11 then was held 11/12/12. (a)  An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Partially Implimented/Adequate Progress CSS 4-12-13 Regulation 2380.91 was reviewed with the Program Supervisor by the Assistant Director of Adult Services. Program Specialist will be responsible for ensuring that individuals who do not attend the scheduled Fire Safety training are trained via video on the next day of attendance. See Attachments B & H. 03/15/2013 Implemented
2380.113(c)(2)There was no Tuberculin skin test noted on the 4/23/12 physical exam for Staff person #1. (c)  The physical examination shall include:(2)  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.Partially Implimented/Adequate Progress CSS 4-12-13 The Program Supervisor will be responsible for reviewing all physicals prior to the first day of employment to ensure they are fully completed. Program Supervisor will be responsible for ensuring a letter stating the need for Tuberculin skin testing is given to all potential employees along with their physical form. See Attachments C & D. 03/15/2013 Implemented
2380.127(b)Individual #1's medication log and the script label on the medication did not match for the medication Lorazepam 1mg PRN. The medication log stated "1 tab every 1/2 hr as needed for 10 or more verbal repitions in 5 mins Max 4/24 hrs. The medication label on the medication stated " 1 tab 1/2 hr PRN agitation/not responding to redirection in 3 min not to exceed 4/24 hrs. (b)  Prescription medications and injections shall be administered according to the directions specified on the prescription.Partially Implimented/Adequate Progress 5-28-13 CSS Program Supervisor will be responsible for on-going monitoring of the medication log to ensure compliance with all regulations. Program Supervisor will review the medication log weekly, and complete a MAR Review form that will be kept in the medication log. MAR Review forms will be reviewed by the Assistant Director of Adult Services to ensure compliance. See Attachment E. 04/30/2015 Implemented
2380.173(9)The 12/12/12 assessment for Individual #1 stated he was diagnosed with Autism, but was not listed on the physical or in the ISP. (9)  Content discrepancies in the ISP, the annual update or revision under §  2380.186.Partially Implimented/Adequate progress 5-28-13 CSS Final version of ISP will be reviewed with assessment and physical to ensure there are no discrepancies. Program Specialist or Program Instructor will be responsible for reviewing these documents and completing a review checklist. Any discrpepancies will be noted and the Supports Coordinator will be informed of the need for revision. See Attachment F. 03/15/2013 Implemented
2380.181(e)(10)The LMH for Individual #1 was attached on 2/23/13, but the assessment had been completed on 12/12/12. (e)  The assessment must include the following information: (10)  A lifetime medical history.Partially Implimented/Adequate Progress 5-28-13 CSS Regulation 181 was reviewed with the Program Specialist by the Assistant Director of Adult Services. Program Supervisor will not replace the medical history sent with the individual's annual assessment with a more current one. Updates will be noted on the medical history and initialed and dated at the time of entry. See Attachment G. 03/15/2013 Implemented
2380.181(f)The assessment for Individual #1 was not sent out 30 days prior to the ISP meeting. The assessment was dated 12/12/12 and was sent out 12/14/12. The ISP meeting was held 12/14/12. (f)  The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Partially Implemented/Adequate Progress 5-28-13 CSS Program Supervisor had been following the directions of the Supports Coordination Unit, who requested assessments be brought to the ISP meeting. Program Specialist will now send assessment to the team 30 days prior to the ISP meeting as required by 181 (f). Attachment will be sent after next assessment is completed on May 18, 2013. 05/19/2013 Implemented
SIN-00207704 Renewal 08/26/2022 Compliant - Finalized