Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.53(a) | Two bottles of bathroom cleaner were stored under the first aid bed, unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist, Apryl Howard, Program Supervisor, Sharon Rodemaker, Program Instructor, Heidi Forsythe, Program Instructor, and Hub 1 and Hub 2 Program Aides
CORRECTIVE ACTION(S) TAKEN
¿ Poisonous materials found (2 aerosol cleaners) were immediately removed from the program area and locked in a cabinet inside the Supervisors offices as evidenced by 3 photographs of the cleared first aid bed area, the container housing the aerosol cleaners with locked padlock, and the placement of the locked container underneath the supervisor¿s desk area. (Attachment #21)
¿ Program Supervisors, Instructors and Program Aides were retrained in 55 PA Code Chapter 2380.53(a) regarding keeping poisonous materials locked and/or inaccessible to individuals when not in use. (Attachment #1)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors, Instructors and Program Aides will ensure that all poisonous materials are kept locked and/or inaccessible to individuals when not in use.
¿ Program Supervisors will ensure that the key to the locked cabinet is only accessible to staff.
¿ Weekly Facility Safety & Compliance Review will be completed to include a functional check of the locking mechanisms on cabinets housing poisonous material. This Review will also include a walk-through of the area to confirm that no poisonous materials are left accessible to individuals to ensure continuous safe-keeping. (Attachment #20) |
09/08/2017
| Implemented |
2380.89(c) | The 2/17/17, 6/29/17, and 7/27/17 fire drill log did not indicate if all smoke detectors were operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ A fire drill was completed on 9/20/2017 at 10:45am. Test mode was requested through Central Monitoring during duration of the drill. Program Supervisor ensured accurate and required documentation of operative fire alarm system. (Attachment #19)
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.89(c) regarding the documentation of operative fire alarm/smoke detector systems. (Attachment #1)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisor will ensure ongoing complete and accurate documentation of fire drills, to include the date, time, amount of time required to evacuate, exit route used, problems encountered and whether the fire alarm system was operative answered with ¿Yes¿ or ¿No¿ as evidenced in 10/13/2017 fire drill. (Attachment #19)
¿ In the event that the fire alarm system cannot be tested or is inoperative, Facility Maintenance is to be notified for immediate repair and a program walk-through check conducted.
¿ Weekly Facility Safety & Compliance Review will be completed to include a check of the fire alarm system control box located at the front E. Emaus entrance of the program to ensure that mode is ¿ready.¿ (Attachment #20) |
12/30/2017
| Implemented |
2380.89(g) | All fire drill logs did not indicate if all individuals evacuated to the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ A fire drill was completed on 9/20/2017 at 10:45am. Program Supervisor ensured accurate and required documentation of all individuals evacuating to the designated meeting place.
¿ On documentation presented at licensing for fire drills completed August 2016 ¿ August 2017, Supervisors erred in documenting the initials and number of persons evacuating to meeting place but not specifically confirming that they reached the meeting place.
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.89(g) regarding the documentation of all individuals evacuating to the designated meeting place. (Attachment #1)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure ongoing complete and accurate documentation of fire drills by continuing to document the initials and number of persons evacuating to meeting place as well as confirming that they reached the meeting place with ¿Yes to Meeting Place¿ as evidenced in 10/13/2017 fire drill. (Attachment #19) |
10/13/2017
| Implemented |
2380.89(h) | The 2/17/17, 4/10/17, 5/30/17, 6/29/17, and 7/27/17 fire drills were not initiated by a fire alarm. The fire drills logs indicate a verbal announcement was made. | A fire alarm shall be set off during each fire drill. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.89(h) regarding the initiation of fire drills by a fire alarm. (Attachment #1)
¿ Upon recognizing this discrepancy on 8/25/2017, Supervisors ensured that the following fire drill was initiated by a fire alarm and documented correctly on the monthly fire drill record on 8/28/17, prior to the licensing review date.
¿ A fire drill was completed on 9/20/2017 at 10:45am. Test mode was requested through Central Monitoring in order to activate the fire alarm system to initiate the fire evacuation drill. Program Supervisor ensured accurate and required documentation of this initiation of the fire drill by a fire alarm. (Attachment #19) |
09/20/2017
| Implemented |
2380.111(c)(7) | Individual #1's 4/19/17 physical exam does not include health maintenance needs. The section was blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.111(c)(7). (Attachment #1)
¿ Individual #1¿s physical exam was completed in the area of health maintenance needs, to include medication regimen. (Attachment #16)
¿ Program Supervisor has ensured that the health maintenance needs section is completed on physical examinations received for each individual attending the program. (Attachment #17)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisor will ensure that all physical exams received by individuals receiving services from program are completed thoroughly and accurately.
¿ Physical letter notices sent to Supports Coordinators and providers/caregivers will specify the requirement that all sections of the physical exam are relevant and necessary to documenting and assessing the individual¿s ongoing health and must be filled out in complete form for acceptance by the program. (Attachment #18)
Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
10/10/2017
| Implemented |
2380.111(c)(10) | Individual #1's 4/19/17 physical exam does not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.111(c)(10). (Attachment #1)
¿ Individual #1¿s physical exam was completed in the area of medical information pertinent to diagnosis and treatment in case of an emergency. (Attachment #16)
¿ Program Supervisor has ensured that the section addressing medical information pertinent to diagnosis and treatment in case of an emergency is completed on physical examinations received for each individual attending the program. (Attachment #17)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisor will ensure that all physical exams received by individuals receiving services from program are completed thoroughly and accurately.
¿ Physical letter notices sent to Supports Coordinators and providers/caregivers will specify the requirement that all sections of the physical exam are relevant and necessary to documenting and assessing the individual¿s ongoing health and must be filled out in complete form for acceptance by the program. (Attachment #18)
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
10/10/2017
| Implemented |
2380.111(c)(11) | Individual #1's 4/19/17 physical exam does not include diet instructions. This section was blank. | The physical examination shall include: Special instructions for an individual's diet. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.111(c)(11). (Attachment #1)
¿ Individual #1¿s physical exam was completed in the section addressing diet instructions. (Attachment #16)
¿ Program Supervisor has ensured that the section addressing diet instructions is completed on physical examinations received for each individual attending the program. (Attachment #17)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisor will ensure that all physical exams received by individuals receiving services from program are completed thoroughly and accurately.
¿ Physical letter notices sent to Supports Coordinators and providers/caregivers will specify the requirement that all sections of the physical exam are relevant and necessary to documenting and assessing the individual¿s ongoing health and must be filled out in complete form for acceptance by the program. (Attachment #18)
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
10/10/2017
| Implemented |
2380.122(a) | Individual #3's Novolog insulin pen did not have a pharmaceutical label. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual¿s name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist, & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Supervisor obtained copy of original label for the Novolog insulin pen with a pharmaceutical label that included the individual¿s name, the name of medication, the date the prescription was issued, the prescribed dose, and the name of the prescribing physician. (Attachment #14)
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.122(a) regarding retaining original containers for prescription medications with a pharmaceutical label including individual¿s name, name of the medication, date prescription was issued, prescribed dose and prescribing physician . (Attachment #1)
¿ Program Supervisor has ensured that all medications administered at the day program have the complete pharmaceutical label as required and listed above. (Attachment #15)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisor will ensure that all medications received to be administered at the day program have the complete pharmaceutical label as required and listed above upon receipt. |
09/30/2017
| Implemented |
2380.173(9) | Individual #2's Individual Support Plan indicated he/she is aware of poisonous materials however, the assessment indicated he/she is not safe with poisonous materials. Individual #1's physical exam indicated an allergy to iodine however, the Individual Support Plan does not list iodine as an allergy. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist, Apryl Howard, Program Supervisor, & Kim Schin, SC
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.173(9). (Attachment #1)
¿ A Criticial Revision to ISP was completed on 9/26/2017 by Kim Schin, SC, to include iodine allergy as documented on the most recent physical. (Attachment #13)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that the medical information documented in the ISP, physical examination reports, assessments, and other individual records corresponds and is accurate.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.176(a) | Individual records were unlocked on a white shelf in the main program area. | Individual records shall be kept locked when they are unattended. | Deirdre Frey, Program Specialist, Apryl Howard, Program Supervisor, Sharon Rodemaker, Program Instructor, Heidi Forsythe, Program Instructor, and Hub 1 and Hub 2 Program Aides
CORRECTIVE ACTION(S) TAKEN
¿ Individual records were immediately removed from the program area and locked in a cabinet inside the Supervisors offices as evidenced by 3 photographs of the books, the books within the cabinet, and the lock on the doors of the cabinet. (Attachment #11)
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.176(a) regarding keeping individual records locked when unattended. (Attachment #1)
¿ Program Supervisors, Instructors and Program Aides were retrained in HIPAA and confidentiality of individual records, as well as the procedures for daily documentation of the individual records and returning of the books to the locked cabinet when not attended to. (Attachment #12)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Instructor will ensure that the books have been returned to the locked cabinet immediately after staff use. (Attachment #12)
¿ Program Supervisors will ensure that the key to the locked cabinet is only accessible to staff who are approved to provide services and therefore document this provision.(Attachment #12)
¿ Weekly Facility Safety & Compliance Review will be completed to include a functional check of the locking mechanism and continuous safe-keeping of individual records. (Attachment #4) |
10/13/2017
| Implemented |
2380.181(e)(9) | Individual #2's 4/5/17 assessment did not include functional or medical limitations. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.181(e)(9). (Attachment #1)
¿ An Addendum to Individual #2s Assessment dated 4/5/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to include documentation of individual¿s disability, including functional or medical limitations. (Attachment #6)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that assessments are completed with documentation of individual¿s disability, including individual¿s age, functional and medical limitations according to medical documentation and information documented in the ISP.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.181(e)(10) | Individual #2's 4/5/17 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.181(e)(10). (Attachment #1)
¿ The Current Health Status section of Individual #2¿s ISP dated 9/26/2017 was attached to the Assessment dated 4/5/2017 to reflect the updated medical information at the time of the Assessment report since the Lifetime Medical History dated 10/24/2013. (Attachment #6)
¿ Individual¿s Lifetime Medical History dated 10/24/2013 for Individual #2s was attached to the Assessment dated 4/5/2017. (Attachment #6)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that assessments are completed with the most updated lifetime medical history.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.181(e)(13)(ii) | Individual #2's 4/5/17 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.181(e)(13)(ii). (Attachment #1)
¿ An Addendum to Individual #2s Assessment dated 4/5/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to include documentation of individual¿s progress over the past year in motor and communication skills. (Attachment #6)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that assessments are completed to include progress over the previous year in motor and communication skills.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.181(e)(13)(iii) | Individual #2's 4/5/17 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.181(e)(13)(iii). (Attachment #1)
¿ An Addendum to Individual #2s Assessment dated 4/5/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to include documentation of individual¿s progress over the past year in personal adjustment. (Attachment #6)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that assessments are completed to include progress over the previous year in personal adjustment.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.181(e)(13)(iv) | Individual #2's 4/5/17 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.181(e)(13)(iv). (Attachment #1)
¿ An Addendum to Individual #2s Assessment dated 4/5/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to include documentation of individual¿s progress over the past year in socialization. (Attachment #6)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that assessments are completed to include progress over the previous year in socialization.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.181(e)(13)(v) | Individual #2's 4/5/17 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.181(e)(13)(iv). (Attachment #1)
¿ An Addendum to Individual #2s Assessment dated 4/5/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to include documentation of individual¿s progress over the past year in socialization. (Attachment #6)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that assessments are completed to include progress over the previous year in socialization.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.181(e)(13)(vi) | Individual #2's 4/5/17 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.181(e)(13)(iv). (Attachment #1)
¿ An Addendum to Individual #2s Assessment dated 4/5/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to include documentation of individual¿s progress over the past year in community integration. (Attachment #6)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisors will ensure that assessments are completed to include progress over the previous year in community integration.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.183(5) | Individual #2's Individual Support Plan did not include his/her 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. | PERSON(S) RESPONSIBLE
Apryl Howard, Program Supervisor & Kim Schin, CMU Supports Coordinator
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.183(5). (Attachment #1)
¿ A Criticial Revision to ISP was completed on 9/26/2017 by Kim Schin, SC, to include a protocol to address the social, emotional, environmental needs of the individual as reflected in the Behavioral Support Plan section. (Attachment #10)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Supervisor will ensure that future ISPs are completed to include the social, emotional, environmental needs plan to address the social, emotional, and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.184(a)(1)(ii) | The program specialist, or qualified designee, did not attend Individual #2's Individual Support Plan 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 program specialist or family living specialist, as applicable, from each provider delivering a service to the individual. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.184(a)(1)(ii). (Attachment #1)
¿ Program Specialist was promptly informed of upcoming ISP meetings and has attended all ISP meetings since date of licensing review on 9/8/2017. (Attachment #8)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Program Specialist will receive ISP meeting invitations ongoing as evidenced by 10/10/2017 invitation to Individual #1 ISP. (Attachment #9)
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
12/30/2017
| Implemented |
2380.186(a) | Staff #2 completed Individual #2's Individual Support Plan reviews. Staff #2 is not a program specialist. | 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor (Staff #2) were retrained in 55 PA Code Chapter 2380.186(a) regarding completion of ISP reviews by a program specialist. (Attachment #1)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ Staff #2 and a Program Specialist will complete all ISP reviews together as evidenced by signatures to confirm collaborative preparation of review. (Attachment #2, Attachment #3)
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
10/13/2017
| Implemented |
2380.186(c)(1) | Individual #2's Individual Support Plan (ISP) reviews did not include participation towards the "task completion" ISP outcome. | 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. | Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.186(c)1. (Attachment #1)
¿ An Addendum to Individual #2s ISP review dated 8/9/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to reflect participation towards ¿task completion¿ ISP outcome. (Attachment #5)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ ISP Reviews will be completed to include monthly documentation of an individual¿s participation and progress towards ISP outcomes in the last quarter as evidenced by Individual #1 Quarterly Review dated 9/15/2017. (Attachment #2)
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
10/11/2017
| Implemented |
2380.186(c)(2) | Individual #2's Individual Support Plan 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter 2380.186(c)(2). (Attachment #1)
¿ An Addendum to Individual #2s ISP review dated 8/9/2017 was completed on 10/11/2017 by Program Specialist and Program Supervisor to reflect the review of the social, emotional, environmental needs plan. (Attachment #6)
¿ Staff were inserviced on the information in the 10/11/2017 Addendum to the Assessment dated 8/9/2017. (Attachment #7)
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ ISP Reviews will be completed to include a review of each section of the ISP, including the social, emotional, environmental needs plan as evidenced by Individual #1 Quarterly Review dated 9/15/2017. (Attachment #2)
¿ Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) |
10/11/2017
| Implemented |
Article X.1007 | United Cerebral Palsy of Central Pa is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Olde Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 resided out of state within the past two years. An FBI clearance was not completed. | 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. | PERSON(S) RESPONSIBLE
Deirdre Frey, Program Specialist & Apryl Howard, Program Supervisor
CORRECTIVE ACTION(S) TAKEN
¿ Program Specialist and Program Supervisor were retrained in 55 PA Code Chapter Article X.1007 regarding the completion of FBI clearances for employees having resided out of state within the last 2 years. (Attachment #1)
¿ Staff #1 has submitted a request form for FBI/PATCH Criminal History Record and received receipt of FBI fingerprinting registration. (Attachment #22) Anticipated completion date for this corrective action is November 1, 2017, with submission of fingerprinting results to Human Resources.
PREVENTATIVE MEASURE(S) IMPLEMENTED
¿ As per current policy, UCP of Central PA requires FBI/PATCH Criminal History Records for all incoming employees working within its adult day programs. (Attachment #23)
¿ Quarterly reviews of employee files will be completed with agency-approved New Hire & Licensing Checklists to ensure compliance in this area. (Attachment #24) |
10/30/2017
| Implemented |