Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00177510 Renewal 01/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff #1 had her physical completed on 1/26/2018. According to regulation 2380.113a, her biannual physical was due on or before 1/26/2020 however her physical was not completed until 7/02/2020. Appendix k and COVID are not factors due to the pandemic occurring in March of 2020 and her physical was due approximately 2 months prior to the pandemic occurring.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.Immediate Corrective Action: Confirmed current physical on file for all staff. Attachment for Employee #1 includes a physical from 2018 and physical from 2020 that were completed on time. POC: A Smart Sheet tracking sheet has been created that will give automatic email notifications to the Supervisors and Program Managers 60 days out, 30 days out and then 15 days out from the due date of the physical. The Supervisors are primarily responsible, with the Program Managers providing over sight. When the physical is completed, the Smart Sheet tracking will be updated attaching the physical form to the sheet. If this update is not completed by 15 days out from the due date, the Director will also receive the email notification, at which time a suspension of employment will be announced if not received within 15 days. UCP's Human Resource department will also track employee qualifications such as annual trainings, physical and TB due dates and other employment information. 01/19/2021 Implemented
2380.113(c)(2)Staff #1 had her PPD completed on 1/29/2018. According to regulation 2380.113.c.2, her biannual PPD would have been due on or before 1/29/2020; however she did not have her PPD completed until 6/25/2020. Appendix K and COVID are not factors due to the pandemic occurring in March of 2020 and her PPD was due approximately 2 months prior to the pandemic occurring.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Immediate Corrective Action: Confirmed current PPD on file for all staff. Attachment for Employee #1 includes a PPD reading for 2018 and PPD reading from 2020 that were completed on time. POC: A Smart Sheet tracking sheet has been created that will give automatic email notifications to the Supervisors and Program Managers 60 days out, 30 days out and then 15 days out from the due date of the PPD. The Supervisors are primarily responsible, with the Program Managers providing over sight. When the PPD is completed, the Smart Sheet tracking will be updated attaching the PPD results form to the sheet. If this update is not completed by 15 days out from the due date, the Director will also receive the email notification, at which time a suspension of employment will be announced if not received within 15 days. UCP's Human Resource department will also track employee qualifications such as annual trainings, physical and PPD due dates and other employment information. 01/19/2021 Implemented
SIN-00159642 Renewal 10/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)An unannounced fire drill wasn't held in the month of July in 2019.An unannounced fire drill shall be held at least once a month.This regulation is important to ensure that staff are prepared and well versed, and that both staff and he individuals are comfortable and confident in safely exiting the building safely. -An unannounced fire drill was not conducted in July 2019. An unannounced fire drill shall be held at least once per month. -This occurred as an oversight by the Supervisor. -Program Specialist/Supervisor was retrained on 55 PA Code Chapter 2380.89(a) (Attachment # 1) -Direct support professionals were retrained in 55 PA Code Chapter 2380.89(a) 10/30/2019 Implemented
2380.89(c)Smoke detectors were not checked during the fire drill conducted on 12.6.18.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.This regulation is important to protect the health and safety of the individuals, as well as the staff that are providing a service. It is important to assure that any problems with the system should be noted and corrected in a timely manner. -Documentation indicated that smoke detectors were not checked during the fire drill conducted on 12/06/18. -Staff mistakenly listed ¿n/a¿ on the record/log instead of indicating that there were no problems. -All staff at this location have been retrained on 2380 regulations pertaining to written documentation of fire drills .[89(c)] -The supervisor will review the record log after a drill has been conducted and documentation has been made. If a supervisor is conducting the drill and documenting on the log, she/he will request that another staff view the log for completion. 10/30/2019 Implemented
2380.111(c)(3)Individual #2 received a Tetanus/Diphtheria Immunization on 05/04/09. Tetanus/Diphtheria immunizations are required every ten years. The Tetanus/Diphtheria immunization is overdue.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.This regulation is important for the health, safety, and well-being of the individuals. -Individual #2 received a tetanus/diphtheria immunization on 05/04/09. Tetanus/Diphtheria immunizations are required every 10 years. The tetanus/diphtheria immunization is overdue. -Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333 -This was due to an oversight on the part of the Program Specialist/supervisor. - Individual #2 was scheduled to have an updated tetanus/diphtheria immunization. Supervisor/Program Specialist has been retrained in 2380 regulations pertaining to 111(c)(3)-tetanus/diphtheria immunizations. -Supervisors will review physicals for completion on the day that they receive them. They will reach out for any necessary corrections and/or missing information at that time. They will then forward to their Managers for an additional review. -Quarterly audits of individual records will be completed within the CPS sites using agency approved worksheets to assure compliance in this area. 10/30/2019 Implemented
2380.111(c)(5)Individual #1's Previous TB test read date was not available during the time of inspection. Not able to ensure TB test was completed every 2 years. Her most recent TB test was read on 9/26/17. Individual #2's received a TB screening on 12/09/16. He has not received a TB screening in 2018. TB screenings are required every two years.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.This regulation is important to assure that precautions are taken to prevent exposure of Tuberculous to other participants and staff. -Individual #1's previous TB read date was not available during the time of inspection. Most recent TB test on file was dated, as having been read, on 09/26/17. Individual #2¿s last noted TB screening was in 2018 -Necessary purged items were not available for Licensor's review.for Individual #1. -Program Supervisor/Specialist has been trained in 2380 regulations, specifically 111(c)(5). The physical examination shall include TB skin testing negative results every two (2) years; of if a positive read, an initial chest X-ray with results noted. -Quarterly audits of individual records will be completed within the program using agency approved worksheets to assure compliance in this area. -Supervisors will review physicals for completion on the day that they receive them. They will reach out for any necessary corrections and/or missing information at that time. They will then forward to their Managers for additional review 10/30/2019 Implemented
2380.176(a)Communication log binder for Individual #3 was found unlocked and unattended on desk near bean bag in front of the ATF.Individual records shall be kept locked when they are unattended.This regulation is important to protect the privacy and confidentiality of the individuals. -Individual #3¿s communication binder was found unlocked and unattended while not in use. -This occurred as an oversight of staff as individual arrived to the facility. - Program Specialist and direct support workers were retrained on 2380 regulations pertaining to individuals¿ records being locked up when they are not being attended to. -Individuals' records are kept locked while not in immediate use; being attended to. -Program Specialist/Supervisor and coordinator will do sweeps of the floor several times during CPS operations hours to assure that confidential records are kept locked up while not in use/being attended to. 10/30/2019 Implemented
2380.181(e)(6)Individual #1's (Individual support plan) ISP dated 9/12/19 states that Linda understands the dangers associated with poisonous substance and uses cleaning supplies appropriately.The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.This regulation is important to ensure the health and safety of all individuals. This information is important to all team members. -Individual #1- ISP dated 09/12/19 states that the individual understands the dangers of poisonous substances and uses cleaning supplies appropriately. Whereas the assessment indicates that she is not aware of the dangers associated with poisonous substances; that they are kept locked up at CPS Mechanicsburg. -This occurred due to a lack of communication between The team members. -Program Supervisor/Specialist was retrained on 2380 regulations specific to 181(e)6); ability to safely use of avoid poisonous materials. -Discussion will be held with Individual #1's team members to clarify her ability to safely use of avoid poisonous materials and to use cleaning supplies appropriately. -The program specialist will make sure All aspects of an individual¿s assessment will be reviewed at ISP meetings. 10/30/2019 Implemented
2380.33(b)(2)Staff #1 was not informed of the following Program Specialist responsibilities. She was not informed of her PS responsibility to coordinate the training of Direct services workers in the content of health and safety needs relevant to each individual, to report a change related to the individual's needs to the SC or plan lead, as applicable, and plan team members, to supervise, monitor and evaluate the services provided to the individual, to Implement the ISP as written and to report content discrepancy to the SC and plan team members.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.This regulation is important to ensure that direct support workers are aware of the individual¿s current needs and the level of support required to meet the needs. It¿s important that all team members are aware of the individual¿s current needs and level of support required to meet those needs. Program Specialist was not informed of the following responsibilities: for providing training to direct service workers in the content of health and safety needs relevant to each individual, to report a change related to the individual¿s needs to the SC or plan lead, as applicable, and plan team members; to supervisor, monitor and evaluate the services provided to the individual; to implement the ISP as written; and to report discrepancies to the SC and plan team members. Additionally, the program specialist was not informed of the responsibility to participate in the individual plan process, development, team reviews, and implementation in accordance with this chapter. ' This occurred due to the lack of documented training, on the part of the mentor and supervisor. -Program Specialist has been retrained in 55 PA Code Chapter 2380.33(b)(2) (attachment #1) -Review of the 2380 regulations, specifically 2380.33(b)(2) will be included in the Supervisor/Program Specialist training curriculum. 10/30/2019 Implemented
2380.181(b)Individual #1's Lifetime medical history attached to annual assessment dated 8/16/19 wasn't updated. Lifetime medical history attached was dated 8/13/13 and didn't include updated information (medical information, medications, correct age, etc.)If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.This regulation is important to ensure that service outcomes and objectives accurately reflect the individual¿s current status. It is important to document all components, including the support needed for the change(s) in services or outcome. Individual #1 - LMH was dated 08/13/13. There was no indication of any updates that had occurred. This occurred due to the supervisor(s) not correctly documenting any changes that had occurred since 2013. -Program Specialist has been retrained in 55 PA Code Chapter 2380.181(b) attachment #2 -Program Specialist will ensure that LMHs are updated as they are aware of changes to a participant's medical background. -Program Specialist has ensured that other LMHs have been updated and indicated as such; in a timely manner. (attachment JS LMH Update). -As a preventative measure to ensure perpetual readiness and ongoing compliance, LMHs will be removed at the time of yearly physicals and at ISP meetings to prompt the program specialist that the LMH needs reviewed/updated at this time. 10/30/2019 Implemented
SIN-00138594 Renewal 10/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(a)Staff 2 was hired on 4/9/18, no documentation of training in daily operations or policy and procedures.The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.¿ This regulation is important because without informed knowledge of the layout of one¿s work environment, including policies and procedures, it could lead to safety issues. It is also vital that staff understand their responsibilities pertaining to the supports of the individuals attending the program. ¿ DSP reviewed does not have documentation indicating that she had onsite training specific to this location. ¿ This was an oversight on the part of the Program Supervisor in the course of orienting the new DSP. Acting Program Supervisor/Specialist has been trained in 2380 regulations; 36 (a). (Attachment 1) ¿ Attached is the signed copy of the reviewed staff¿s onsite orientation (Attachment 2). ¿ Program Supervisor/Specialist will use new hire/employee checklists to assure that all aspects of onsite orientations are completed with new hires (Attachment 3). ¿ Quarterly audits of staff records will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.36(d)Staff 2 was hired on 4/9/18, no documentation of training in program planning and implementation.Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.¿ This regulation is important because so that new staff can be given the necessary tools to be able to provide services to the program participants; based upon their needs and as outlined in their ISPs. ¿ DSP does not have documentation indicating that she had instruction in providing services into individuals with disabilities; additionally program planning and implementation. ¿ This was an oversight on the part of the Program Supervisor in the course of orienting the new DSP. ¿ Acting Program Supervisor/Specialist has been trained in 2380 regulations; specifically 36(d). ¿ Attached is the signed copy of the reviewed staff¿s onsite orientation (Attachment 2). ¿ Program Supervisor/Specialist will use new hire/employee checklists to assure that all aspects of onsite orientations are completed with new hires (Attachment 3). ¿ Quarterly audits of staff records will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.88(f)Fire extinguishers inspected 4/18/18. No documentation of 2017 inspection.Fire extinguishers shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.¿ This regulation is important so that extinguishers are available in the event of a fire that staff are sure have been inspected and are full functional. ¿ Extinguishers were missing check cards that indicate that extinguishers are full. ¿ A program participant routinely removes the cards from the extinguishers and disposes of them. ¿ Acting Program Supervisor/Specialist has been trained in 2380 regulations; specifically 89(f). ¿ Kint has provided stickers to be kept on extinguishers to avoid having cards removed by participants (Attachment #4). ¿ In order to show compliance across programs in this regulation, attached is a picture of a fire extinguisher tag as displayed in all UCP sites (Attachment 5). ¿ Quarterly audits of fire safety will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.89(e)Alternative routes- from 9/6/2018 to 10/11/2017 only the front door was used as the exit for the fire drill when there is a back door that can be used as an exit.Alternate exit routes shall be used during fire drills.¿ This regulation is important because providers must ensure that individuals are familiar with egress out of all exits in the event of a real emergency, ¿ Program documentation indicates that only one (1) route was used during fire drills. ¿ This was an oversight on the part of the Program Supervisor when conducting fire drills. ¿ Acting Program Supervisor/Specialist has been trained in 2380 regulations; specifically 89(e). ¿ Ongoing, Program Supervisor/Specialist will use alternate routes when conducting fire and emergency drills (Attachment #7) . ¿ To show compliance across records, fire drill record indicating use of alternating exit routes is attached (Attachment #8) ¿ Quarterly audits of fire safety will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.111(c)(5)Individual 1's TB test was completed on 2/28/18. No documentation of prior TB test notated.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.¿ This regulation is important to assure that precautions are taken to prevent exposure of Tuberculous to other participants and staff. ¿ Previous physical of Individual #1 was missing previous year¿s physical indicating date of most recent TB skin test. Copy provided was located within file. ¿ Previous physical was overlooked in file. It was located with the assessment vs under with other medical documents/physical (Attachment #9). ¿ Acting Program Supervisor/Specialist has been trained in 2380 regulations; specifically 111(c)(5). ¿ Program Supervisor will ensure accurate filing is completed in order to quickly locate needed documentation. ¿ Quarterly audits of individual records will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.111(c)(10)Individual 1's 2/26/18 physical exam did not include information pertinent to diagnosis and treatment in the event of an emergency. section blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.¿ This regulation is important so that staff can be properly prepared to provide necessary treatment and/or make necessary arrangements in the event of an emergency situation. ¿ Information was missing from the physical of Individual #1 pertaining to diagnosis and treatment in the event of an emergency. This has been corrected (Attachment #10) ¿ A physical was accepted as completed and placed in file; missing required information. ¿ Acting Program Supervisor/Specialist has been trained in 2380 regulations; specifically 111(c)(10). ¿ In order to show compliance across records, a physical is being submitted to evidence this regulation (attachment #11) ¿ Required areas will be highlighted, in advance, on physical forms. Supervisor/Program Specialist will review physical for completion prior to accepting and filing. ¿ Quarterly audits of individual records will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.123(b)SEEN plan- individual 2 does not have a SEEN plan in place in the ISP for Day Programming to assist her with diagnosis of mood disorder. Individual 2 does not have a SEEN Plan that addresses his social, emotional, or environmental needs. Plan just includes medication given for MH diagnosis.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.¿ This regulation is important because it is necessary to know if an individual¿s SEEN plan is serving its purpose, needs revised, and/or was important of a time frame; to be utilized in any format. ¿ Individual #2¿s (JH) was not included in the ISP review. ¿ This was an oversight on the part of the Program Supervisor/Specialist. ¿ An addendum has been created and added to the review (attachment #12). ¿ Acting Program Supervisor/Specialist has been instructed in 2380 regulations; particularly 123(b); addressing a SEEN plan as it applies to an individual that takes psychotropic medications. ¿ Program Supervisor/Specialist will use a checklist to assure all necessary areas are addressed; as pertains to the SEEN plan in ISP reviews. ¿ Quarterly audits of individual records will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.173(9)Individual 1's physical indicated to follow a dairy free, low fat, low cholesterol, low sodium diet. ISP states low fat, low salt, low acid, and limit caffeine.Each individuals record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.¿ This regulation is important because documentation of changes in an individual¿s medical status is knowledge that staff should be made aware of. Existing and new staff would be responsible for reading any new and/or revised ISPs with any changes noted. ¿ Individual #1 (KG) had discrepancies in his annual physical in comparison to his ISP ¿ Program Supervisor/Specialist did not notify SC in any changes that needed to be made in ISP in comparison to individual¿s annual physical. ¿ Acting Program Supervisor/Specialist will notify SC of discrepancies and request that changes be made in individual¿s ISP (Attachment #13). ¿ Acting Program Supervisor/Specialist has been instructed in 2380 codes; particularly 173(9) as it pertains to content discrepancy. ¿ Program Supervisor/Specialist will compare all incoming annual physicals with ISP contents. Discrepancies will be noted and addressed with SC. This will be done by completing quarterly audits on agency approved worksheets (attachment #6). 10/15/2018 Implemented
2380.176(a)Individual Records locked- The individuals program records-books were unlocked that contained personal information regarding the individuals care.Individual records shall be kept locked when they are unattended.¿ This regulation is important as the individual¿s records contain confidential information. ¿ The key for the cabinet containing individual records, was left in the cabinet during licensing visit. Key will not remain in cabinet unless UCP staff are in direct proximity of cabinet containing individual records. ¿ Acting Program Supervisor/Specialist has been instructed in PA 2380 regulations; specifically 176(a) as it pertains to individual records being locked. ¿ The key for the cabinet that stores individual records will be kept in a separate area; cabinet locked when a UCP staff is not directly present. ¿ Locked documentation is evidenced in attachments #15, 16. ¿ Quarterly audits of physical site will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.181(e)(4)Supervision- The 4/13/18 Assessment for individual 2 did not assess her supervision needs. on page 17 of the assessment, this section was left blank.The assessment must include the following information: The individual's need for supervision.¿ This regulation is important because it reflects the level of supervision an individual needs both in the community and program. ¿ The supervision needs of Individual #2 was not properly documented in the outcomes. ¿ This was an oversight on the part of the Program Supervisor/Specialist. ¿ An addendum has been completed to reflect the individual¿s level of supervision needed both within program and in the community (attachment #17). ¿ To evidence recent compliance across records, a compliant assessment is submitted (attachment #18) ¿ Acting Program Supervisor/Specialist has been trained in 2380 regulations; specifically documentation of an individual¿s level of supervision needed both in community and program; importance of documenting within Assessment. ¿ Quarterly audits of individual files will be completed within the program using agency approved worksheets to assure compliance in this area. 10/15/2018 Implemented
2380.181(e)(10)Lifetime medical History- The 4/13/18 Assessment for Individual 2 did not contain an updated lifetime medical history. There was a 2017 physical, but the section said see attached, no attachments. There was also a 2015 LMH, but no current information.The assessment must include the following information: A lifetime medical history.¿ This regulation is important at it gives staff more background knowledge of the individual; information relevant to maintaining the safety of the individual. ¿ The assessment for individual #2 did not include a lifetime medical history. ¿ This was an oversight on the part of the Program Supervisor/Specialist. ¿ A lifetime medical history has been added to the individual¿s assessment. (Attachment #17) ¿ Program Supervisor/Specialist has been instructed in 2380 regulations; specifically the importance of including an individual¿s lifetime medical history in their assessment. ¿ Quarterly audits of individual files will be conducted within program using an agency approved audit form to assure compliance in this area. 10/15/2018 Implemented
2380.181(e)(12)Recommendations for training and services- The recommendation section in the 4/13/18 assessment for individual 2 was left blank. This was not assessed for services or training.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.¿ This regulation is important because all team members should be knowledgeable of level of ability and interest in training, vocational programming and competitive-integrated employment. ¿ The assessment for Individual #2 did not include recommendations for specific areas of training, vocational programming and competitive-integrated employment. ¿ This was an oversight on the part of the Program Supervisor/Specialist ¿ An addendum has been completed to include recommendations for specific areas of training, vocational programming, and competitive-integrated employment (attachment #17). ¿ To evidence recent compliance across records, a compliant assessment is submitted (attachment #18) ¿ Program Supervisor/Specialist has been instructed in 2380 regulations; specifically the importance of including an individual¿s training, vocational programming, and competitive-integrated employment in their assessment. ¿ Quarterly audits of individual files will be conducted within program using an agency approved audit form to assure compliance in this area (Attachment #6). 10/15/2018 Implemented
2380.186(b)ISP Reviews- The 2/3/18 and 5/3/18 reviews were not dated by individual 2.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.¿ This regulation is important as it shows that the review was presented to the individual in a timely manner. ¿ Date of ISP review, by the individual, were not indicated on two (2) reviews. ¿ This occurred due to the absence of a full-time supervisor over a period of time this year. ¿ In order to evidence compliance, a recent ISP review sign sheet is being submitted (Attachment #19, 20) ¿ Program Supervisor/Specialist has been instructed in 2380 regulations; specifically the importance of dates of quarterly reviews with individual. ¿ Quarterly audits of individual files will be conducted within program using an agency approved audit form to assure compliance in this area (Attachment #6). 10/15/2018 Implemented
2380.186(c)(1)Individual 1- ISP review dated 8/3/18 does not include participation or progress made on physical exercise outcome. Review indicated complete data could not be collected. Progress would not be accurate. 5/3/18, 2/3/18,11/3/17 review does not include participation and progress towards physical exercise outcome.The ISP review must include the following: A review of the monthly documentation of an individuals participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.¿ This regulation is important because it documents goals worked with this particular individual, participation in program activities, outings, changes/progress in medical, behavioral, and personal growth, and individual¿s SEEN plan; if they have one (1). ¿ The ISP review for individual #1 did not indicate level of progress and areas of participation. ¿ This was an oversight on the part of the Program Supervisor/Specialist. This program has been without a fulltime supervisor for a period of time this year. ¿ An addendum has been created to include level of progress in/and areas of participation (Attachment #12). ¿ To evidence compliance across records, a recent ISP review has been submitted (Attachment #21) ¿ Program Supervisor/Specialist has been instructed in 2380 regulations; specifically accurate ISP reviews of individuals. ¿ Quarterly audits of individual records will be completed within program using agency approved audit worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
2380.186(d)Individual 1's 8/3/18, ISP review not sent to plan team members.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.¿ This regulation is important so that team members can review the material in a timely manner in order for changes to be made as needed. ¿ The file did not contain a letter for a quarterly review, dated 08/21/18, for individual #1. ¿ This was an oversight on the part of the Acting Program Supervisor. ¿ A copy of a timely letter has been included for review to evidence compliance across records (Attachment #22). ¿ Program Supervisor/Specialist has been instructed in 2380 regulations; specifically notifying teams members in a timely manner of a review. ¿ Quarterly audits of individual records will be completed within program using agency approved audit worksheets to assure compliance in this area (attachment #6). 10/15/2018 Implemented
SIN-00120057 Renewal 09/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)Individual #2 entered into the program on 2/21/17. Staff were trained up until 9/15/17 on an Individual Support Plan (ISP) for Individual #2 that was last updated on 4/25/16. Staff were not trained on any updated health and safety needs for Individual #2 until 9/25/17. Individual #2's ISP was updated 18 times from 4/25/16 until present which included a change in staffing requirement at day program. Staff #3's date of hire was 9/6/16 and she was not trained in Individual #2's ISP until 2/19/17, which was a very old and outdated plan.This section is being used to define the responsibilities for the program specialistThe Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #8 ISP review Staff Sign-Off for new Individual #1 Date of Admission 9/25/17 and Attachment #15 ISP for new intake Individual #1 dated 9/13/17 10/17/2017 Implemented
2380.36(a)Staff #3's date of hire was 9/6/16 and Staff #4's date of hire was 10/4/16. Neither staff received orientation to staff persons relevant to their responsibilities, the daily operations of the facility and policies and procedures. The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 28 & 29 On-Site orientation for Staff # 3 and Attachment # 30 On-sit orientation for Staff #4. Also refer to Attachment # 22 On-Site orientation Checklist for new hire AH dated 10/9 to 10/13/17 10/17/2017 Implemented
2380.36(d)Staff #3's date of hire was 9/6/16 and Staff #4's date of hire was 10/4/16. Neither staff received training in the areas of services for people with disabilities and program planning and implementation. Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 28 & 29 On-Site orientation for Staff # 3 and Attachment # 30 On-sit orientation for Staff #4. Also refer to Attachment # 22 On-Site orientation Checklist for new hire AH dated 10/9 to 10/13/17 10/17/2017 Implemented
2380.36(e)Staff #3's date of hire was 9/6/16 and she did not receive training in general fire safety yet. 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 is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 28 & 29 On-Site orientation for Staff # 3. Also refer to Attachment # 22 On-Site orientation Checklist for new hire AH dated 10/9 to 10/13/17 10/17/2017 Implemented
2380.55(a)The curtain in the first aid room was dirty and had red and orange smears and particles of matter stuck to the curtain. Clean and sanitary conditions shall be maintained in the facility.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment Attachment #3 - all Staff review and sign ¿off on regulation referring to keeping the curtain clean and checking for stains on a regular basis. 10/17/2017 Implemented
2380.55(d)The large trashcan in the kitchen did not have the lid on the trashcan. Per staff at the program, the lid is normally on the foor like it was today, 9/12/17.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #3 Staff review and sign-off referring to keeping the trash receptacles covered. 10/17/2017 Implemented
2380.67(a)The picnic table, located in the back parking lot of the building, had many wooden boards that were warped and had splinters sticking up. Furniture and equipment shall be nonhazardous, clean and sturdy.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #3 - all Staff review and sign ¿off on regulation referring to keeping equipment clean, sturdy and non-hazardous condition Also refer to Attachment # 27 FiiX work order report confirming the table was removed. 10/17/2017 Implemented
2380.82The kitchen table and chairs were blocking the door leading to the life fit room. The door only opened approximately 1 foot. Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to 10/17/2017 Implemented
2380.87(b)Individual #4 has a hearing impairment and the first aid room did not have a strobe visible in the room when the curtain was pulled closed in 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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 25 work order from Law Security confirming the installation of an additional strobe in the changing area. 10/17/2017 Implemented
2380.88(f)There was no documentation at the facility that the fire extinguishers were inspected annually by a firesafety expert. Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #23 Bill from KINT for annual Extinguisher inspection completed 6/21/17 and Attachment #24 Tag from Fire Extinguisher noting monthly checks. 10/17/2017 Implemented
2380.113(a)Staff #2's date of hire was 5/22/17 and her physical was not completed until 5/22/17.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 is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. HR department and Program Supervisor will confirm the receipt of completed physical prior to scheduling the staff for orientation. Also refer to Attachment # 19 pages 1 to 6 New Hire Orientation for Staff AH DOH 10/9/17 and Attachement # 20 Physical for staff AH date of completion 10/6/17. 10/17/2017 Implemented
2380.124(a)Individual #3's May 2017-August 2017 medication administration record (mar) indicated that he/she was prescribed Lorazepam .5mg, take 1 tablet by mouth 4 times/day, 6am, 10am, 3pm, and 6pm. However according to Individual #3's medication label for Lorazepam indicated the times of administration was 6am, 10am, 2pm, and 6pm. Individual #3's May 2017 mar did not have a time of administration for the second dose of Lorazepam. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #18A October MAR for Individual #3 with correct times entered as per medication packet and 18B Medication Packet for Individual #3. 10/17/2017 Implemented
2380.124(b)Staff #5 administered medication to Individual #3 today, 9/26/17, and she signed the medication administration record prior to administering the medication. The information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. 10/11/2017 Implemented
2380.128(e)Staff #6's 3/3/17 medication training practicum did not contain documentation for the medication administration record (mar) reviews completed for Staff #6. The completed mar reviews were missing from the entire medication practicum packet. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 16 complete medication Training Packet for Staff #6 SB and Attachment # 17 Complete medication training packet for staff MP completed on 9/29/17. 10/17/2017 Implemented
2380.173(9)Individual #2's Individual Support Plan (ISP) indicated he/she was to follow a 1600 calorie diet with 60-70 grams of carbohydrates at meals and 15-30 grams of carbohydrates with night snack. His/Her 10/3/16 physical indicated he/she was on a 1600 calorie ADA diet with 60-70 grams of carbohydrates at meals and 15-30 grams of carbohydrates with night snack. His/Her 5/19/17 assessment indicated he/she was on a 166 calorie diet with 40-60 grams of carbohydrates per meal. His/Her ISP indicated that he/she could be left unsupervised in a vehicle in the community for up to 15 minutes. This is not included in his/her assessment. Individual #1's lifetime medical history indicated that he/she was to follow a 45 gm of carbohydrates per meal, 10 gm of carbohydrates or less for the mid-morning and afternoon snacks, 25-30 gm of carbohydrates for evening snacks, and eat 1100-1400 calorie range per day. Individual #1's ISP only indicated that he/she was to follow a low carbohydrate diet. Individual #1's ISP indicated he/she had an allergy to Vera Wang princess perfume but this was not listed anywhere else in his/her record. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 10 Assessment for MR dated 10/6/17 and Attachment # 15 page 1 to 48 Individual #1's ISP dated 9/13/17 to compare for the absence of discrepancies. Also refer to Attachment #13 letter for changes to Individual #1's Assessment and Attachment #14 letter regarding updates to individual # 2's Assessment. 10/17/2017 Implemented
2380.181(a)Individual #2's date of admission was 2/21/17 and his/her assessment was not completed until 5/19/17.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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 9 Letter to team regarding initial assessment for new Individual #1 dated 10/13/17 and Attachment # 10 ¿ Assessment for new Individual #1 with Date of Admission 9/25/17. 10/17/2017 Implemented
2380.181(b)Individual #2 stated receiving 1:1 staff to individual ratio on 8/21/17 and the program specialist did not complete an updated assessment to address the change in service for Individual #2. If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under §  2380.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 11 Email to Individual #1's team regarding changes to assessment including the need for 1:1 support and Attachment # 12 Individual #1's assessment dated 10/13/17 10/17/2017 Implemented
2380.181(d)REPEAT from 8/26/16 annual inspection: Individual #1's assessment was not dated by the program specialist. The program specialist shall sign and date the assessment.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 10 ¿ Assessment for Individual #1 dated 10/13/17. 10/17/2017 Implemented
2380.181(e)(3)(iii)Individual #1's 8/18/17 assessment did not include his/her current performance in the area of personal adjustment. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Personal adjustment.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 10 Assessment for Individual #1 date 10/13/17 and Attachment # 13A Updated assessment letter to team for Individual #2 and Attachment #13B updated assessment for Individual #2 which includes personal adjustment. 10/17/2017 Implemented
2380.181(e)(5)Individual #1's 8/18/17 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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 10 Assessment for MR date 10/13/17 and Attachment # 13A Updated assessment letter to team for Individual #1 and Attachment #13B updated assessment for Individual #1 which includes ability to self-administer medication 10/17/2017 Implemented
2380.181(e)(6)Individual #2's 5/19/17 assessment did not include his/her ability to safely use or avoid poisonous materials. The assessment indicated he/she was not safe around poisons but also that he/she could safely use poisons. The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #10 assessment for MR dated 10/6/17 with all required information , Attachment #11 letter for Individual #1s updated assessment, Attachment # 12 Updated assessment for Individual #1 dated 10/13/17 and Attachment #14 letter regarding updated assessment information to Individual #1's team 10/17/2017 Implemented
2380.181(e)(12)Individual #1's 8/18/17 assessment did not include recommendations for the 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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 10 Assessment for Individual #1 date 10/6/17 with all required information and Attachment # 13A Letter to Individual #2's team regarding updated assessment and Attachment #13B Updated Assessment for Individual #2 including information on Community Integrated employment. 10/17/2017 Implemented
2380.181(e)(13)(iii)REPEAT from 8/26/16 annual inspection: Individual #1's 8/18/17 assessment did not include progress in personal adjustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 10 Assessment for Individual #1 date 10/6/17 with all required information and Attachment # 13A Letter to Individual #1's team regarding updated assessment and Attachment #13B Updated Assessment for Individual #1 including information on Personal Adjustment 10/17/2017 Implemented
2380.181(e)(13)(iv)REPEAT from 8/26/16 annual inspection: Individual #1's 8/18/17 assessment did not include progress in socialization. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 10 Assessment for Individual #1 date 10/6/17 with all required information and Attachment # 13A Letter toIndividual #2's team regarding updated assessment and Attachment #13B Updated Assessment for Individual #2 including information socialization. 10/17/2017 Implemented
2380.181(f)There was no documentation that Individual #2's 5/19/17 assessment or Individual #1's 8/18/17 assessment was sent to any team members. The correspondance letter was blank for who the assessment was sent to. 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 is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 9 Letter to Individual #1 with cc to all team members and Attachment # 13A letter to Individual #2 with cc to team members. 10/17/2017 Implemented
2380.186(b)REPEAT from 8/26/16 annual inspection: Individual #1 did not sign and date his/her Individual Support Plan (ISP) reviews completed on 9/7/17 and 9/7/16.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 4-B ISP Review for Individual #1 signed by Program Specialist and assistant Director dated 10/6/17 10/17/2017 Implemented
2380.186(c)(1)Individual #2's Individual Support Plan (ISP) review completed on 5/19/17 was to review the months of March-May 2017. His/Her 8/19/17 ISP review was to review the months of June-August 2017. Individual #2's day program outcome to write his/her address was not address on either ISP review from 5/20/17-5/31/17. Neither ISP reivew reviewed Individual #2's participation and progress on his/her outcome. Daily notes indicated Individual #2 was working on vocalizing his/her address when his/her ISP review indicated he/she was working on copying his/her address. 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 is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #4-A ISP Review for Individual #1 with goal sheet clarification dated 10/17/17 and Attachment #4B ISP Review for Individual #1 dated 10/6/17 10/17/2017 Implemented
2380.186(c)(2)REPEAT from 8/26/16 annual inspection: Individual #2's behavior support plan and behaviors of yelling, pounding, pushing, and hitting were not reviewed on his/her 8/19/17 Individual Support Plan (ISP) review. The review indicated that Individual #2 had 10 episodes of hitting in the past quarter. However Individual #2 had 28 incidents of yelling, 6 incidents of pounding, and 5 incidents of hitting in June 2017 alone. The July 2017 log was missing from his/her record. He/she had recorded 5 incidents of yelling and 2 incidents of hitting in August 2017. Individual #1's 9/7/17, 6/7/17, 3/7/17, 12/7/17, and 9/7/17 ISP reviews and Individual #2's 8/9/17 and 5/19/17 ISP reviews did not review their community participation. All the ISP reviews for every individual at the program had a blanket statement in their ISP reviews discussing some of the outings other people at the program went on during the quarter. The only community participation provided to Individual #2 was on 8/1/17 and 5/22/17 according to daily outing logs. The last community outing offered to Individual #1 was on 5/15/17. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment 4-B ISP Review for PS dated 10/6/17 and Attachment # 6 pages 1to3 Behavior logs for PS and Attachment #7pages 1to3 Activity logs for PS used to provide information on Isp Review dated 10/6/17. 10/17/2017 Implemented
2380.186(d)There was no documentation in Individual #2's record that would indicate his/her 5/19/17 Individual Support Plan (ISP) review was sent to any team member. The correspondance letter was blank for who it was sent to. Individual #2's 8/19/17 ISP review was not sent to his/her behavior support person. There was no documentation that any of Individual #1's ISP reviews, 9/7/17, 6/7/17, 3/7/17, 12/7/16, and 9/7/16 were sent to team members. 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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment # 5 Letter to PS¿s regarding ISP Review dated 10/6/17 with cc to team members behavior support staff. 10/17/2017 Implemented
2380.186(e)Individual #2's behavior support person was not offered the option to decline his/her Individual Support Plan (ISP) review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. Also refer to Attachment #5 Letter to PS¿s team regarding ISP Review with the option to decline documentation. 10/17/2017 Implemented
Article X.1007Elwyn Institute is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 was hired on 9/11/17; the criminal history check was requested on 9/18/17.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At The Mechanicsburg Alternatives Program the Assistant Director is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to attachment # 1 Inspection Citation Sign-off signed by Candice Bostdorf on 10/11/17 and verified by Assistant Director Kathleen Smith, Attachment #2 program Specialist Responsibilities Sign-off signed by Candice Bostdorf on 10/11/17, reviewed by assistant Director Kathleen Smith. In an effort to ensure ongoing compliance, UCP will be conducting internal audits of programs on a quarterly basis. The audit teams will be external to the individual program. Documentation of the audits will be maintained by the Director of Adult Services. All areas of non-compliance identified through the audit will be corrected within ten days. The HR Department and Program Supervisor will confirm receipt of all required documentation prior to scheduling staff to attend new hire orientation. Also refer to Attachment #19 New Hire Orientation Check List for staff AH Date of Hire 10/9/17 and Attachment # 21 Criminal Background for staff AH dated 9/21/17. 10/17/2017 Implemented
SIN-00099695 Renewal 08/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's 6/10/16 physical exam was completed late. The previous exam was completed on 5/25/15.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #16 Individual physical for Individual #1 dated 9/11/15 and Attachment #17 page 1 to 6 physical for Individual #1 dated 9/12/16 showing physical done within mandated time frame 09/12/2016 Implemented
2380.111(c)(4)Individual #2's 3/15/16 physical exam did not include information regarding a vision and hearing screening. This section was not completed by the physician.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #17 page 1 to 7 Individual physical for MH dated 9/12/16 including information on vision and hearing Also refer to Attachment #18 page 1 to 4 physical for Individual #2 corrected 09/12/2016 Implemented
2380.111(c)(10)Individual #3's 10/8/15 physical exam did not include information pertinent to diagnsis and treatment in case of an emergecy. This section was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #17 page 1 to 7 Individual physical for MH dated 9/12/16 including information in event of an emergency. Also refer to Attachment #19 Physical for Individual #3 corrected. 09/12/2016 Implemented
2380.113(c)(2)Staff #1's 8/23/16 tuberculin test was completed late. The previous testing was completed on 5/9/14.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment 14 staff physical dated 9/10/16 and Attachment #16 staff pyysical dated 9/15/14 showing TB test done within mandated time frame 09/12/2016 Implemented
2380.128(a)Staff #2 transferred to United Cerebral Palsy's Alternatives program on 1/1/15 from another agency. Staff #2 transferred his/her medication training but did not complete a practicum summary prior to passing medications for United Cerebral Palsy.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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #9 page 1 to 18 Medication Training for Staff SS recertification practicum with UCP and original training transferred from SKILLS 09/27/2016 Implemented
2380.181(d)Individual #3's assessment was not dated by the program specialist.The program specialist shall sign and date the assessment.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #6 Cover Sheet for Consumer #3¿ Assessment dated 11/8/15 and Attachment #7 page 1 Cover sheet for Individual #1¿s Assessment dated 6/14/16 signed and dated by Program Specialist and Program Manager 09/27/2016 Implemented
2380.181(e)(10)Individual #1's 6/15/16 assessment did not include an updated lifetime medical history. The assessment must include the following information: A lifetime medical history.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #6 Cover Sheet for Consumer #3¿ Assessment dated 11/8/15 and Attachment #7 page 1 Cover sheet for Individual #1¿s Assessment dated 6/14/16 and page 1 to 26 signed and dated by Program Specialist and Program Manager with medical history attached. 09/27/2016 Implemented
2380.181(e)(13)(ii)Individual #1's 6/15/16 assessment and Individual #3's 11/17/15 assessment did not include progress over the past year in motor and communication skills.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #8 page 1A to 18 Assessment for Individual #1 dated 9/12/16 signed and dated by the Program Specialist and Program Manager which includes information on Motor and communication Skills over the past year. 09/14/2016 Implemented
2380.181(e)(13)(iii)Individual #1's 6/15/16 assessment and Individual #3's 11/17/15 assessment did not include progress over the past year in personal adjustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #8 page 1A to 18 Assessment for Individual #1 dated 9/12/16 signed and dated by the Program Specialist and Program Manager which includes information on Personal Adjustment over the past year 09/14/2016 Implemented
2380.181(e)(13)(iv)Individual #1's 6/15/16 assessment and Individual #3's 11/17/15 assessment did not include progress over the past year in socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #8 page 1A to 18 Assessment for Individual Individual#1 dated 9/12/16 signed and dated by the Program Specialist and Program Manager which includes information on Socialization over the past year 09/14/2016 Implemented
2380.181(e)(13)(v)Individual #1's 6/15/16 assessment and Individual #3's 11/17/15 assessment did not include progress over the past year 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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #8 page 1A to 18 Assessment for Individual DL dated 9/12/16 signed and dated by the Program Specialist and Program Manager which includes information on Recreation over the past year 09/14/2016 Implemented
2380.181(e)(13)(vi)Individual #1's 6/15/16 assessment did not include progress 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.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #8 page 1A to 18 Assessment for Individual #1 dated 9/12/16 signed and dated by the Program Specialist and Program Manager which includes information on Community Integration over the past year 09/14/2016 Implemented
2380.183(5)Individual #3's Individual Support Plan did not include a social, emotional, environmental needs plan. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #4 Email to Supports Coordinator requesting the SEEN Plan for Consumer #3 be added to his ISP 09/27/2016 Implemented
2380.183(7)(i)Individual #1's Individual Support Plan did not include potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #5 Email to Supports Coordinator requesting the information on Vocational Programming be added to Individual # 1¿s ISP 09/27/2016 Implemented
2380.183(7)(iii)Individual #1's Individual Support Plan did not include potential to advance in competitive employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #5 Email to Supports Coordinator requesting the information on Competitive Employment be added to Individual # 1¿s ISP 09/27/2016 Implemented
2380.184(a)(1)(iii)A direct care staff person was not present at Individual #1's 9/2/15 Individual Support Plan (ISP) meeting or Individual #3's 1/12/16 ISP meeting.The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision).A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering a service to the individual.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #3 ISP Sign-in sheet dated 9/21/16 attended by and signed by Direct Care Staff #2 09/21/2016 Implemented
2380.186(b)REPEATED VIOLATOIN - 5/27/15 Individual #3's 9/7/15 Individual Support Plan (ISP review was not signed and dated by the program specialist or Individual #3.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #2 page 1 to 5 ISP Quarterly Review for consumer #3 dated 9/7/16 completed by the Program Specialist/Supervisor and reviewed by the Program Manager and signed by Consumer #3. 09/27/2016 Implemented
2380.186(c)(2)Individual #3's 6/7/16, 3/7/16, 12/7/15, and 9/7/15 Individual Support Plan (ISP) reviews did not include a review of the social, emotional, environmental, needs plan.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Mechanicsburg Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1 to 7 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #2 page 1 to 5 ISP Quarterly Review for consumer #3 dated 9/7/16 completed by the Program Specialist/Supervisor and reviewed by the Program Manager which includes SEEN Plan 09/27/2016 Implemented
SIN-00079140 Renewal 05/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #2 had a tuberculin skin test on 7/13/2011 and then again on 8/1/2013. This was outside of the 2 year time frame. 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.2380.111( c) (5) - The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. Please refer to Attachment # 1 page 1, 2 &3 - Staff Training Log dated 8/24/15 and signed by the current program Specialist/Supervisor Shelly Henninger. Also refer to Attachment #4 page 2 TB results done 7/30/13 for Consumer #2 and Attachment #7 page 3 TB results completed 3/30/15 for Consumer #2 which is in the 2 year time frame required. 08/24/2015 Implemented
2380.173(1)(ii)Individual #3's record did not include identifying marks. 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.2380.173(1) (ii) - The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. Please refer to Attachment # 1 page 1, 2 &3 - Staff Training Log dated 8/24/15 and signed by the current program Specialist/Supervisor Shelly Henninger. Also refer to Attachment #2 Personal Info form for Consumer # 3 - updated with missing information and Attachment # 3 Personal Info Form for new Consumer JK dated 6/1/15 with all information included. 08/24/2015 Implemented
2380.173(1)(iv)Individual #3's record did not include religious afflication. Each individual¿s record must include the following information: Personal information including: Religious affiliation.2380.173(1) (IV) - The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. Please refer to Attachment # 1 page 1, 2 &3 - Staff Training Log dated 8/24/15 and signed by the current program Specialist/Supervisor Shelly Henninger. Also refer to Attachment #2 Personal Info form for Consumer # 3 ¿ updated with missing information and Attachment # 3 Personal Info Form for new Consumer dated 6/1/15 with all information included. 08/24/2015 Implemented
2380.173(9)Individual #2's Physical stated that she was allergic to sulfisoazole and the ISP stated she was allergic to tomato sauce and has seasonal allergies. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.2380.173(9) - The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. Please refer to Attachment # 1 page 1, 2 &3 - Staff Training Log dated 8/24/15 and signed by the current program Specialist/Supervisor Shelly Henninger. Also refer to Attachment #4 Consumer #2 page 1 to 4 - Physical dated 7/15/14 with allergy section corrected on page 1 and page 5 ISP allergy section matching physical. Also refer to Attachment # 5 ISP for consumer Individual #1 dated 8/21/15 allergy section and Attachment # 6 page 1 to 3 physical for Consumer Individual #1 dated 7/16/15 page 1 allergy section that matches the physical. 08/24/2015 Implemented
2380.186(b)Individual #2's ISP reviews were not signed by the program specialist and the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.  Implemented
SIN-00075897 Unannounced Monitoring 02/12/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16Individual #1's Individual Suport Plan (ISP) stated he had 3:1 (individual to staff ratio) while at day program. On 2/9/15 Individual #1 ate lunch and took his medications around noon. A few minutes after 12 noon, day program Staff #5 sat with Individual #1 in the front room to the right of the entryway to play with balls out of his sensory ball basket for a few minutes, according to witness statements. Staff #5 left the area a few minutes after working with Individual #1. The sensory basket full of different shaped/colored balls sat next to Individual #1 within arms reach until 2:30pm according to witness statements. After Staff #5 stopped working with Individual #1, staff didn't check on Individual #1 until staff took him to the first aid room to change him around 2:15pm-2:20pm. Staff #4 and Staff #1 changed Individual #1. Staff #1 and #4 did not notice a blue ball in Individual #1's mouth or throat. By this time, Individual #1 had to have swallowed the ball before being changed, since staff was with him every minute after this. After Individual #1 was changed and brought back into the front room, his residential staff came to pick him up around 2:30pm. In a 2 hour time frame from when Individual #1 ate lunch until he was changed, there were no staff in a position to provide supervision to Individual #1 to see how he acquired the blue ball and put it in his mouth. His 3:1 supervision level was not maintained. The blue ball eventually was logged in his throat, caused him to choke, stop breathing, and be rushed to the emergency room a few hours later. He stayed overnight in the emergency room to ensure more damage did not occur. Staff #3 stated that the facility had a game for about a year which had many 3 inch diameter, blue, plastic, balls that were filled with air. Staff #3 stated that the game broke but the facility would still find the blue balls around the facility. Staff #3 has found multiple blue balls in baskets sitting around the facility. 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 2380.16 The Program Specialist/Supervisor is responsible to ensure that all documentation is completed and that all 2380 regulations are followed by staff. Please refer to attachment # 4 Staff training Log signed by B Kreiser. Also see attachment # 12 ISP for TR dated 5/7/16 pages 9 to 11 and 34to 35 addressing level of support 05/29/2015 Implemented
2380.55(a)In the first aid room, there was a used changing pad lying on top of clean adult briefs that were opened out of the adult brief packages. The changing pad had short, dark, hairs all over it. In the first aid room, shoved behind the cabinets to the right of the entry way, was clothes that had dirt and dust gathered on them. No staff knew how long the clothes were shoved back there. The bathroom connected to the first aid room had dried blood spatters on the wall to the right of the toilet (underneath the toilet paper holder) and on the wall behind the toilet. The toilet itself had dried feces stuck to inside of the back of the toilet. The amount of feces was approximately 3 different spots, 1 inch in diameter. There were many spots (5 inches in diameter) of dried urine on the floor all around the toilet in the same bathroom. There were approximately 3 adult briefs on the bottom shelves of the cubbies in the coat room that were out of their plastic wrapped packages and other dirty items (shoes) were sitting on top of them. There was an open women¿s menstruation pad lying on top of clothes and other items on the bottom shelf of one cubby. There were unmarked underwear on the floor to the right of the cubbies on the left side wall, exposed to dirt. There were other unmarked underwear thrown on the very top of the same cubbies. The plaid blanket that Individual #2 was using had dried food and dirt all over the blanket. The reclining chair/bed that Individual #2 used had mud dried at the bottom of the bed where his feet would be placed if he were lying down. Individual #3 was fed via g-tube. Day program staff stated that after Individual #3 eats, his g-tube needs to be cleaned, sanitized, and to air dry in a sanitary environment. Individual #3's g-tube was lying on a paper towel, on top of the microwave only about 4 feet off the ground and completely exposed to indiviudal's and staff's touch/contamination. Clean and sanitary conditions shall be maintained in the facility.  Implemented
2380.55(c)Outside of the UCP building, in the back of the building, there were many broken pieces of furniture that had been there for months. There was a broken reclining love seat, broken wooden bench, two broken metal and wood chairs, broken sand box, and one broken bench swing. Staff stated it had been outside the back of the building for many months and nobody had removed the broken debris. Trash shall be removed from the premises at least once per week.  Implemented
2380.57The fan light in the bathroom attached to the first aid room, would not turn on. The light was right above the sink in that bathroom. Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.  Implemented
2380.58(a)Above the sink in the front bathroom there were holes in the wall from a former soap dispenser. The back of the mirror in the same bathroom was peeling off. There were many paint chips on the walls in the front bathroom and on the same bathroom door. About a foot off the floor on the wall leading into the first aid room, there were paint chips and paint scraped off the wall. The corner of the same wall was exposed due to a large amount of paint pealing off that wall. The doorway leading from the coat room into the lunch room had paint and wall scrapes about a foot off the ground as well; exposing the corner framing. The door and door frame leading from the front room into the coat room had the same paint, wall, and wood chipping about a foot from the ground. In the front room, to the left of the front entrance where Individual #2 spent most of his time, there were approximately 10, 4-5 inch holes that were not patched over properly, about 3 feet from the bottom of the wall. The corner of the right hand side of the kitchen county was peeling off and only attached by tape. The two top drawers on the microwave stand were broken and would not pull out completely. In the TV room, along the wall adjacent to the doorway into the room, there were 6, 2-3 inch holes in the wall about 3 feet from the bottom of the wall. Floors, walls, ceilings and other surfaces shall be in good repair.  Implemented
2380.58(b)There was a 6 foot tall, white, self-standing cabinet at the end of the bed in the first aid room. The cabinet was broken, unsteady, and wobbled easily back and forth. There were contents in the broken cabinet. The cabinet was within arm¿s reach of any individual lying on the first aid bed, making it a hazard if it were to fall. Floors, walls, ceilings and other surfaces shall be free of hazards.  Implemented
2380.59(a)The water temperature was only 75 degrees Fahrenheit. It did not get hot.The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas.  Implemented
2380.62Emergency telephone numbers were not on the working telephone in the kitchen. There were emergency telephone numbers on a non-working phone right next to the working telephone. However staff picked up the working telephone and walked to the front room and office with the working phone, making the emergency numbers not next to the working telephone. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.  Implemented
2380.70(b)The first aid room did not have a pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.  Implemented
2380.82The back exit egress is a ramp. There were two mops lying on the egress ramp, obstructing the full opening of the door and obstructing the exit ramp to evacuate. There were many individuals in wheelchairs that attended the program. Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.  Implemented
2380.89(a)A fire drill was not conducted for the months of May 2014 through September 2014.An unannounced fire drill shall be held at least once a month.  Implemented
2380.89(d)The 2/28/14 fire drill took the individuals 2 minutes and 40 seconds to evacuate the building. Another fire drill was not completed that month. The fire drill on 3/31/14 took the individuals 2 minutes and 37 seconds to evacuate the building. Another fire drill was not completed that month. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.  Implemented
2380.111(c)(6)The communicable disease status on Individual #1's physical from 4/21/14 was left blank. It was unmarked and no explanation was written as to whether Individual #1 was free from communicable disease.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.  Implemented
2380.121(b)Thick-it that was prescribed to Individual #1 was in the cabinet in the lunch room, above the sink to the right, unlocked, and sitting among other food items. Prescription and nonprescription medications shall be kept in an area or container that is locked.  Implemented
2380.181(a)Individual #1 had an annual assessment completed on 2/21/13 and not again until 3/27/14, outside of the annual time frame. 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.  Implemented
2380.181(f)The assessment for Individual #1 that was completed on 3/27/14 was not send to team members. Individual #1's record had a letter written from Program Specialist Clyde Osterhout on 3/5/14 to Individual #1, Residential Laurie Foose, and behavior support Amy Sheely which stated that Clyde was sending the annual assessment to them on 3/5/14. The assessment was not even complete until 3/27/14.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).  Implemented
2380.183(5)There was no SEEN plan in the Individual Support Plan for Individual #1. Staff #1 stated that they are only working on communication support with Individual #1. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.  Implemented
2380.183(7)(ii)Individual #1's Individual Support Plan did not contain his potential to advance in community involvement.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Community involvement.  Implemented
2380.185(b)Individual #1's Individual Support Plan (ISP) stated that United Cerebral Palsy (UCP) was responsible for implementing his Behavior Support Plan (BSP) but UCP was only working on communication support. UCP was not implementing Individual #1's BSP. Individual #1's ISP stated he was to have 3:1 staff to individual ratio at all times while attending the program. However after Individual #1 ate lunch and took his medications around noon, staff only sat with him to play with sensory balls for a few minutes according to witness statements. After that, staff didn't check on Individual #1 until they changed him around 2:15pm-2:20pm. In a 2 hour time frame, there were no staff in a position to provide supervision to Individual #1 to see how he acquired the blue ball and put it in his mouth. Individual #1's 3:1 supervision level was not maintained. The ISP shall be implemented as written.  Implemented
2380.186(a)Individual #1 only had Individual Support Plan reviews completed on 2/5/14 and 5/5/14 for the past and current years. Individual #1 had no reviews completed after 5/5/14 and date of unannounced inspection was 2/12/15.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.  Implemented
2380.186(b)The program specialist, Clyde Osterhout, and Individual #1 did not sign and date the two Individual Support Plan reviews that were completed. The names and dates were prepopulated. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.  Implemented
2380.186(c)(1)The Individual Support Plan (ISP) reviews for Individual #1 were not reviewing the accurate participation towards his two goals. The reviews were reviewing a social activity goal and a music listening goal. The reviews stated Individual #1 was working on step #3 of each goal. However when reviewing monthly documentation, Individual #1 had not achieved step #1 of either goal.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.  Implemented
2380.186(c)(2)Individual #1's 3:1 supervision, behavior support plan, and SEEN plan were not being reviewed in the two Individual Support Plan reviews completed for him. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.  Implemented
2380.186(d)Individual #1's team consisted of Aileen Rider (mother), Lindsey Ferenz (CPARC), Sue Kissinger (CPARC advocate), Clyde Osterhout (UCP program specialist), Amy Sheely (behavior support professional), Laurie Dutz (Pennhurst Advocate), and Deborah Cook (Supports Coordinator). The 2/5/14 Individual Support Plan (ISP) review was only sent to Individual #1, Amy, and Laurie Foose (CPARC). The 5/5/14 ISP review was only sent to Indiviudal #1, Amy, Deborah, and Laurie. The ISP reviews were not sent to all team members.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.  Implemented
2380.186(e)The plan team for Individual #1 was not notified of their option to decline the Individual Support Plan reviews.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.  Implemented
SIN-00072900 Unannounced Monitoring 10/16/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The extra storage room located on the left hand side of the building, attached to the back left program room, contained many cleaning supplies. The door leading from the program room to the storage room was not locked. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. The program specialist is responsible to ensure that all staff are aware of the consumer ISP content and that staff adhere to all 2380 regulations. Please refer to Attachment # 4 ¿ training Log for Specialist, Attachment # 5 page 1 and 4 ¿ Staff Training Log and attachment # 6 door sign reminder to keep door locked. "The Assistance Director of Adult Services for the Mechanicsburg Alternatives site is responsible for monitoring physical site location quarterly to ensure safety of individuals is maintained. The Assistance Director of Adult Services will document their quarterly physical site monitoring and and submit to BHSL licensing every 3 months." -wstum 01/19/2015 Implemented
2380.124(a)Out of the 9 months of medication logs that were available to view, only 5 months contained dates stating what month the medications were given. February, March, April, May, and July 2014 were the only medication logs labeled with dates. There was no time logged for when any medications were given to any individual that took medications during the 9 months of medication logs; for Individual's #1-8. Individual #6 was prescribed Prandin 2mg, 1 tab by mouth on Tuesday and Thursday with 2nd and 3rd meal of the day. Her medication log stated that she was to take Prandin 2mg, by mouth twice a day with 2nd and 3rd meals. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. The program specialist is responsible to ensure that all staff are aware of the consumer ISP content and that staff adhere to all 2380 regulations. Please refer to Attachment # 1 page 1 & 2 - Staff Training Log, Attachment #2 ¿ PRN Checklist, Attachment #3 page 1 to 3 ¿ MAR dated January to March 2015. "The Assistance Director of Adult Services for the Mechanicsburg Alternatives site is responsible for reviewing all Individual's medication logs and medications quarterly to ensure medication administration accuracy. The Assistance Director of Adult Services will document their quarterly medication administration record review of all individuals at the program and submit the review to BHSL licensing every 3 months." -wstum 11/04/2014 Implemented
2380.124(b)Due to the months not being listed on most of the medication administration records, it was determined through attendance records that this citation refers to September 2014. Individual #2 was administered their noon medications on 9/10/14 and 9/15/14. However, Staff #1 forgot to sign off after giving the Thioridazine 100mg, take 1.5 tabs at noon for both days. Staff #1 signed after giving the Klonopin and Strattera at noon on 9/10 and 9/15.The information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication.The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. The program specialist is responsible to ensure that all staff are aware of the consumer ISP content and that staff adhere to all 2380 regulations. Please refer to Attachment # 1 page 1 & 2 - Staff Training Log, Attachment #2 ¿ PRN Checklist, Attachment #3 page 1 to 3 ¿ MAR dated January to March 2015 , "The Assistance Director of Adult Services for the Mechanicsburg Alternatives site is responsible for reviewing all Individual's medication logs and medications quarterly to ensure medication administration accuracy. The Assistance Director of Adult Services will document their quarterly medication administration record review of all individuals at the program and submit the review to BHSL licensing every 3 months." -wstum 11/04/2014 Implemented
2380.125Due to the months not being listed on most of the medication administration records, it was determined through attendance records that Individual #4 missed a dose of Tegretol 100mg at noon on 10/3/14. There was no incident report entered into HCSIS. Documentation of medication errors and follow-up action taken shall be kept.The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. The program specialist is responsible to ensure that all staff are aware of the consumer ISP content and that staff adhere to all 2380 regulations. Please refer to Attachment # 1 page 1 & 2 - Staff Training Log, Attachment #2 ¿ PRN Checklist, Attachment #3 page 1 to 3 ¿ MAR dated January to March 2015 , "The Assistance Director of Adult Services for the Mechanicsburg Alternatives site is responsible for reviewing all Individual's medication logs and medications quarterly to ensure medication administration accuracy. The Assistance Director of Adult Services will document their quarterly medication administration record review of all individuals at the program and submit the review to BHSL licensing every 3 months." -wstum 11/04/2014 Implemented
2380.173(9)Individual #9 had a plan to decrease his 1:1 supervision ratio. This separate plan was not consistsant with the contents of Individual #9's Individual Support Plan (ISP). Individual #9's ISP stated that "the plan allows Individual #9 to experience 15 minutes of independent time. As Individual #9 successfully completed 30 days without any incidents, that will now be increased to two 15 minutes per day. After 30 days with no incident, that will be increased to three 15 minute periods, and so on, until the 1:1 is completely faded." However the separate plan to decrease the 1:1 for Individual #9 stated that "after the initial 10 days are complete without incident his 1:1 will begin to decrease 1:1 staffing for 10 minute increments for every hour that he attends day program. During that time the 1:1 will remain within eye sight of Individual #9. If Individual #9 can maintain the reduced staffing for 30 days without incident then the 1:1 will be decreased for an additional 5 minutes for every hour Individual #9 attends program. If Individual #9 completes this ratio over an additional 30 days, additional fading of the 1:1 will continue until the team makes a determination that Individual #9 can attend at a 1:3 ratio." Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. The program specialist is responsible to ensure that all staff are aware of the consumer ISP content and that staff adhere to all 2380 regulations. Please refer to Attachment # 4 pages 1 to 3 ¿ Staff training Log Attachment # 5 pages 1 to 3 ¿ Staff training Log and Consumer TR¿s ISP indicating level of support when providing personal care.Attachment # 6 & 7 consumer 1:1 Support plan/ decrease support plan. "The Assistance Director of Adult Services for the Mechanicsburg Alternatives site is responsible for reviewing all individual records quarterly to ensure there is no content discrepancy with any individual's records. The Assistance Director of Adult Services will document their review of all individual records and submit to BHSL licensing every 3 months." -wstum 01/19/2015 Implemented
2380.185(b)Individual #1's Individual Support Plan (ISP) stated he is allergic to bee stings and was prescribed Epi-pen, .3mg auto inject, to be administered when stung by a bee. The only Epi-pen available to Individual #1 at the facility expired in August 2014. Individual #4's Medication Administration Record (MAR) and ISP indicated that he was to take Benedryl, 50 mg orally if he was stung by a bee while at day program. The Benedryl for Individual #4 expired in August 2014. There was no other Benedryl available at the program for Individual #4 should they need it. The ISP for Individual #5 stated that "he requires the assistance of 2 staff to change him and 3 staff to lift him back into his chair." During my unanounced inspection, I witnessed Staff #2 taking Individual #5 to the first aid room to be changed. I did not see another staff enter the room to assist. I spoke to Staff #2 via the phone on 10/20/14 and Staff #2 confirmed that "he (Staff #2) normally changes Individual #5 by himself and that Individual #5 is a stand-pivot transfer to change him." Individual #2's ISP stated that his 1:1 staff needed to be within an arms reach. Staff #1 was Individual #2's 1:1 the day of the inspection. Staff #1 left Individual #2 in the kitchen to show me around the program, leaving him without 1:1 supervision and 2 rooms away. Individual #9's ISP stated that he requires line of sight 1:1 superivision while at day program. Individual #9's 1:1 staff is Staff #3. Staff #3 was making lunch in the lunch room while Individual #9 sat at a lunch table, another room away and out of vision from Staff #9. There was a wall in between. Individual #9 has a plan to decrease his 1:1 that was not being followed as per instruction. Staff #3 stated to inspector that she just decreases her 1:1 time with Individual #9 depending on Individual #9's mood, not based on the incident timeline. See October 2014 data for decreasing 1:1 for Individual #9. The ISP shall be implemented as written.The Program Specialist/Supervisor is responsible to ensure that all documentation is completed accurately and in a timely fashion. The program specialist is responsible to ensure that all staff are aware of the consumer ISP content and that staff adhere to all 2380 regulations. Please refer to Attachment # 1 page 1 & 2 - Staff Training Log, Attachment #2 ¿ PRN Checklist, Attachment #3 page 1 to 3 ¿ MAR dated January to March 2015 , Attachment # 4 pages 1 to 3 ¿ Staff Training Log and Attachment # 5 pages 1 to 3 Staff training Log. "The Assistance Director of Adult Services for the Mechanicsburg Alternatives site is responsible for reviewing all Individual's medication logs, medications, and entire records quarterly to ensure medication administration accuracy and that ISP are implemented as written. The Assistance Director of Adult Services will document their quarterly record review of all individual's program books, medications, and medication records at the program and submit the review to BHSL licensing every 3 months." -wstum 01/19/2015 Implemented
SIN-00065842 Renewal 05/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(e)The outside trash bin was full and the lid would not close on the trash bin.Trash outside the facility shall be kept in closed receptacles that prevent the penetration of insects and rodents.Please refer to attachment #5 sign placed on dupmster and arttachment #6 photo of closed dumpster with signs indicating it is for private use. 06/02/2014 Implemented
2380.113(a)The physical for Staff #1 was not completed within the 2-year regulatory requirement.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.Staff # 1 had a physical completed within the time frame however it was not filed at the time of the inspection Please see attachment #3 physical dated 12/3/13 for staff #3 and attachment #1 & 2 physical for staff RK dated within the two year time frame 5/31/12 and 6/2/14 06/02/2014 Implemented
2380.113(c)(2)The TB testing for Staff #1 was not completed within the 2-year regulatory requirement.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Staff # 1 had a physical completed including a TB test within the time frame however it was not filed at the time of the inspection Please see attachment #3 physical dated 12/3/13 for staff #3 and attachment #1 & 2 physical for staff RK dated within the two year time frame5/31/12 and 6/2/14 including TB tests. 06/02/2014 Implemented
2380.186(b)All ISP reviews for Individual #1 were not signed and dated by the Individual. Also, the ISP reviews for Indiviudal #2 were not signed and dated by the Program Specialist and the Individual. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The Program Specialist is responsible to ensure documentation is complete and accurate. Please see attachment # 4 Specialist training form and attachment # 7 ISP review dated 6/5/14 which are signed by the Consumer and program specialist. 06/05/2014 Implemented
2380.186(c)(2)The ISP review, dated 5/14/14, completed for Individual #1 did not include a review of his behavioral support plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Specialist is responsible to ensure documentation is complete and accurate. Please see attachment # 4 Specialist training form and attachment # 7 ISP review dated 6/5/14 which includes behavioral information. 06/05/2014 Implemented
SIN-00046931 Renewal 05/17/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(9)The ISP for Individual #2 indicates that she is on a soft diet and takes nutritional drinks 3 times daily. This information is not listed on her physical. (9)  Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3. Also refer to Document #2 corrected physical for Consumer #2 and document #3 Letter to Supports coordinator 06/06/2013 Implemented
2380.181(a)The assessment for Individual #2 was not updated annually. The current assessment was completed on 2/15/2013. There was no an assessment completed for the prior year. (a)  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.ADEQUATE PROGRESS The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3. Also refer to document #4 ISP Letter for KM, Document # 5 Assesment Cover page for KM dated 6/5/13, Document #6 Assessment letter dated 6/6/13 for KM and document # 7 assessment Cover page for KM previous year dated 6/6/2012 06/06/2013 Implemented
2380.181(e)(3)(i) The assessment for Individual #1 did not include progress in functional skills, communication, personal adjustment, or personal needs. The assessment for Individual #2 did not include progress in functional skills. (e)  The assessment must include the following information: (3)  The individual's current level of performance and progress in the following areas:(i)   Acquisition of functional skills. (ii) communication. (iii) personal adjustment. (iv) personal needsADEQUATE PROGRESS The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3. Also refer to documents attached to email dated 9/13/13 Full assessment for Consumer KM dated 6/6/13. 06/06/2013 Implemented
2380.181(e)(13)(i)The assessment for Individual #1 did not include progress and growth in the areas of health, motor and communication, personal adjustment, socialization, recreation, and community integration. The assessment for Individual #2 did not include progress and growth in the areas of health, socialization, recreation, and community integration. (e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (i)   Health. (ii) motor and communication. (iii) personal adjustment. (iv) socialization. (v) recreation. (vi) community integration.Adequate progress The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3.. Also refer to Document #15 addendum to Consumer #2 assessment 06/10/2013 Implemented
2380.181(f)The assessment for Individual #2 was not sent to plan team members 30 days prior to the ISP meeting. The ISP meeting was held on 3/21/2013. The assessment was sent to plan team members on 3/3/2013.(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).ADEQUATE PROGRESS The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3.Also refer to Document # 4 ISP letter for KM dated 6/10/13 for ISP to be held on 7/11/13 Documnet # 5 Assessment Cover sheet for KM and Document #6 Assessment Letter dated 6/6/13 for KM. 06/05/2013 Implemented
2380.183(7)(ii)The ISP for Individual #2 did not include her potential to advance in community involvement. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: (7)  Assessment of the individual's potential to advance in the following: (ii)   Community involvement.ADEQUATE PROGRESS The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3. Also refer to Document #16 e-mail to Supports coordinator 06/10/2013 Implemented
2380.185(b)Individual #1 has had the same goals for many years. The first goal, implemented on 11/05/2003, is identified as "Individual #1 will walk with staff only holding one of the staff member's arms". There are no additional steps, and little to no progress indicated for the goal since initiation. The second goal, implemented on 12/14/2005, is identified as "Individual #1 will attend to an activity for 30 seconds". There are no additional steps, and little to no progress indicated for the goal since initiation. Neither goal had documentation of the demonstrated progress.(b)  The ISP shall be implemented as written.adequate progress The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3. .Also refer to Document # 8 letter regarding new goals dated 6/26/13, Document #9 ISP sign-in Sheet dated 6/26/13, Document # 10 and Document #11 new Goals for Consumer #1 Document #12 new Goal for Consumer #2 06/26/2013 Implemented
2380.186(a)There were no ISP reviews completed for Individual #1 or Individual #2 between June of 2012 and March of 2013.(a)  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.adequate progress The Program specialist is responsible to ensure that all documentation is completed on time and is accurate. Refer to Document #1 pages 1-3.. Also refer to Document # 13 ISP Quarterly Review for Consumer #1 dated 6/5/13 and Document # 14 ISP Quarterly review for Consumer #1 dated 3/4/13 06/26/2013 Implemented
SIN-00225328 Renewal 05/31/2023 Compliant - Finalized
SIN-00197880 Renewal 04/12/2022 Compliant - Finalized