Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230476 Renewal 09/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisonous hand soap was found in the kitchen soap dispenser during the physical site walk through. (Contact Poison Control was on the soap insert label).Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The pink soap identified as a poison (attachment #1) was replaced with a blue soap (attachment #2) in the dispenser located in the kitchen (Attachment #3 and #4). 09/14/2023 Implemented
2380.111(c)(4)Individual # 1's physical dated 08/01/23 does not include a vision or hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.received a physical on 8/1/23 where her Vision Screening was marked nob for Normal Findings and Yesfor Is further evaluation recommended by the specialist? (Attachment #9 pg2). Attached is also a physical for SS showing that a Vision and Hearing Screening was completed (Attachment #10 pg. 3) 09/14/2023 Implemented
2380.36(b)Staff # 3 received annual fire safety training on 04/08/22 and not again until 04/26/23.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Individual had her Annual Fire Safety on 4/8/2022 (Attachment #5) and again on 4/26/23 (Attachment #6 09/14/2023 Implemented
SIN-00211042 Renewal 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62Emergency numbers were not on two phones in the program areas.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.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. Emergency telephone numbers have been added to the wireless phone backs as well as the handle of the supervisor¿s desk phone. Please see attachment #1 and #2 of the emergency numbers on the back/handle of the phone receivers. 09/20/2022 Implemented
2380.87(b)There is no strobe in the laundry room to alert deaf or hard of hearing individuals of a fire.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.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. An internal request was submitted for the installation of strobe lights in the laundry room. See attachment #3 for the internal FIIX form that was submitted. 09/20/2022 Implemented
2380.182(a)Individual #1's PS did not coordinate the annual ISP revision timely. The individual had an ISP meeting on 6/24/21, then next meeting is not scheduled until 9/20/22.The program specialist shall coordinate the development of the individual plan, including revisions, with the individual and the individual plan team.The program specialist shall coordinate the development of the individual plan, including revisions, with the individual and the individual plan team. All CPS Supervisors will include a reminder of the ISP meeting due date when sending a copy of the updated assessment. 09/20/2022 Implemented
SIN-00178888 Renewal 10/23/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)The men's bathroom floor was extremely slippery during the inspection on 10/22/20. Staff #2 informed that a disinfectant spray is being used after individuals leave the program and there appears to be a slippery film on the floor inside the men's bathroom and on the floor outside of the men's bathroom. Licenser requested that floors be cleaned immediately to ensure that floors are hazard free. Floors were cleaned during on site inspection.Floors, walls, ceilings and other surfaces shall be free of hazards.Upon further investigation, the new cleaning solution purchased to help with disinfecting and killing virus and germs, was not mixed properly causing the floor to be slippery. The supervisor of Middletown CPS spoke with the owner of the cleaning solution company, Global Atmosphere, who emailed the program a wall chart and a pump to use for the gallon jug to have more precise measurements when mixing solution. Please see photo of the pump (Attachment #16) and wall chart (Attachment #15) and the memo to staff about the measurements (Attachment #17). 11/18/2020 Implemented
2380.84Annual Fire safety inspection was completed on 7/2/2019. Current years inspection was due on or before 7/2/2020 however, there has not been an annual fire safety inspection for this year, 2020, and according to staff an inspection has not yet been scheduled either. They opened the facility on October 5th, however, to date (10/22/2020) There is still no documentation supporting that the staff has reached out to the fire department to get this scheduled for this year.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.UCP will start scheduling the annual fire safety inspections to be completed by the company insurance provider. UCP has already contacted the liability insurance company and will be scheduling annual fire safety inspections during the month of April each year for all CPS locations including Middletown. The Director of CPS will be responsible for scheduling the annual fire safety inspection. Please see Fire Safety inspection (Attachment #12) and Property Inspection letter (Attachment #13) 11/18/2020 Implemented
2380.89(a)According to fire drill records, there was no fire drill held for the month of January 2020.An unannounced fire drill shall be held at least once a month.UCP has designated an internal Administrative Coordinator to track and send out monthly reminders to complete fire drills (Attachment #1) and CPS Manager, put an appointment reminder on the supervisors outlook calendars on the 20th of each month as a reoccurring reminder so no further monthly drills are missed. (Attachment #2). 11/18/2020 Implemented
2380.111(c)(7)REPEAT VIOLATION (07/02/19) Individual # 3 most recent physical dated 3/17/2020 did not indicate recommendations for health maintenance; this section of the physical form was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.CPS Supervisors will immediately review all annual physicals when they are received at the facility. The incomplete annual physical form will be returned to the families/guardians of the individuals for them to take with them back to the doctor. All blank areas will be highlighted so the physician is aware of the missing information needed. Supervisors will also start scanning and uploading the completed physicals into a designated computer folder specifically for annual physicals so the manager and director of CPS can assess them to review and provide oversite. Attachment #4 is AW¿s physical as cited and Attachment #7 is another individuals physical with correct information. 11/18/2020 Implemented
2380.111(c)(10)Individual # 2's physical exam dated 05/21/20 does not include information pertinent to diagnosis in case of emergency. The space was left blank. Individual # 3's most recent physical dated 3/17/2020 did not indicate information pertinent to diagnosis and treatment in case of emergency; this section of the physical form was left blankThe physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.CPS Supervisors will immediately review all annual physicals when they are received at the facility. The incomplete annual physical form will be returned to the families/guardians of the individuals for them to take with them back to the doctor. All blank areas will be highlighted so the physician is aware of the missing information needed. Supervisors will also start scanning and uploading the completed physicals into a designated computer folder specifically for annual physicals so the manager and director of CPS can assess them to review and provide oversite. Attachment #3 is MT¿s physical as cited and Attachment #7 is another individuals physical with correct information. 11/18/2020 Implemented
SIN-00162947 Unannounced Monitoring 08/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisons locked- There was a gallon of a disinfectant -Odor Ban behind the door in the first aide/changing room. This room was unlocked during the inspection. Not all Individuals are safe with poisons which require then to be locked when not in use.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Who is Responsible: Program Specialist(s), DSPs This regulation is important to ensure that individuals do not put hazardous substances into their mouths to taste or get the substances on their skin, in eyes etc. The cabinet was left unlocked during program hours. This occurred due to staff not securing the disinfectant after cleaning the changing room. Program Specialist has been trained in 55 PA Code Chapter 2380.53(a) (attachment #5). The poisonous material was put away and locked immediately (See attachments #6-8). All cabinets containing poisonous materials will be locked and the locks will be checked at least (3) three times during the program hours during a walk-through conducted by Supervisors; once in the morning, mid-afternoon, and late afternoon. Locks will be in place for all cabinets containing poisonous materials and locks will be checked for proper installation/closure at least (3) three times a day. Staff are instructed to lock to cabinet after (s)he is completed getting and/or putting back the poisonous materials used. Quarterly internal audits of physical site requirements will be completed within the program and documented to ensure compliance in this area. (Attachment #4) 08/26/2019 Implemented
2380.38(a)(1)Staff training- orientation/responsibilities- On 8/5/19 while conducting the investigation it was noted that UCP is using a temp agency -Milestone. A staff person from Milestone came into the program area and sat with the Individuals and began talking to them. This staff was not trained before working with the Individuals. Milestone does conduct their own training, but UCP is responsible for conducting the orientation prior to staff working with any Individual. This is not implemented. Staff person #5 who had worked with Individual #1 on 7/19/19 was not trained on Individual #1's ISP or BSP according to the sign in sheets for staff.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.Who is Responsible: Program Specialist(s), DSPs This regulation is important because without informed knowledge of the layout of one¿s work environment, including policies and procedures, safety and supervision issues arise. It is also vital that staff understand their responsibilities pertaining to the supports of the individuals attending the program for health, safety, and quality service provision. This was an oversight on the part of the CPS Supervisor in the course of orienting the new staff. Program Specialist has been trained in 55 PA Code Chapter 2380.38(a) (attachment #5). CPS Supervisors/Specialists will ensure the use of site-specific new hire/employee program orientation checklists and DSP position descriptions to confirm that all aspects of onsite orientation are completed with new hires prior to working with individuals (Attachment #9, 10, 11). Quarterly audits of staff records will be completed within the program using agency approved worksheets to assure compliance in this area (attachment #4). 08/26/2019 Implemented
2380.186ISP Implemented- Individual #1's ISP/ BSP plans specify that staff are to follow the plan when there are particular behaviors exhibited. During the incident on 7/19/19, staff #2 was running around the table in the program area to get away from Individual #1. Individual #1's BSP clearly states "that staff should remain calm, don't make sudden movements. Staff should say "Hands done.". Staff did not follow the plan. Staff #1 allowed Individual#1 to chase around the table, and did not remove the other Individuals in that area for safety purposes causing 2 other Individuals to be physically assaulted by Individual #1 which caused one of the Individual to go to the ER to be checked out for injuries. Staff person #2 ran into the office area for their protection, not following the Behavioral Support plan that was put in placeThe facility shall implement the individual plan, including revisions.A Plan of Correction specifically for Individual #1 can not be implemented as requested as Individual #1 no longer attends the CPS Middletown program. Who is Responsible: Program Specialist(s), DSPs This regulation is important to ensure that the needs and supports appropriate for an individual are being provided for to ensure. This citation occurred because staff did not respond as they were trained according to the Behavior Support Plan. It should be noted that staff were inserviced on and had signed for the ISP and BSP reviews on several occasions (Attachment #1, 2, 2.5). Program Specialist has been trained in 55 PA Code Chapter 2380.186(attachment #5). Considering Individual #1 no longer attends the program, as an immediate corrective action and to evidence recent compliance across records, all DSP team members have been inserviced on all ISPs as best practice (Attachment #3). To ensure that this regulation is adhered to in the future, regular reviews of the ISPs and behavior support plans will be conducted by Behavior Specialists and/or Program Specialists to ensure that DSPs are informed and will react appropriately in a crisis situation. Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 08/26/2019 Implemented
SIN-00157497 Renewal 07/02/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(d)Tape was not found in the first aid kit during the inspection.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.The tape was placed in the First Aide Kit at the time of the inspection on 07/02/2019. In addition all staff were retrained on this regulation. In order to avoid this from occurring in the future the Program Specialist place a note in the FA kit reminding staff that if something is removed it must be replaced. Please see attachments #1 and #10. 07/24/2019 Implemented
2380.87(b)Individuals who are hearing impaired attend the adult training facility. Strobe lights are not located in the front/bonus room, sensory room and first aid 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 Facilities manager was notified immediately to make arrangements to have the strobe lights installed in the sensory room and the front room. The equipment has been ordered and will be installed once it arrives. UCP will conduct quarterly audits of their CPS programs to ensure compliance any citation uncovered will have arrangements made for correction immediately. Please see Attachments #1, and #9 08/30/2019 Implemented
2380.111(c)(5)REPEAT From 8/13/18: Individual #1 had a TB test read on 2/24/16 and then again on 3/28/18.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.The Program Specialist and staff were retrained on the TB test regulation. It is the Program Specialists responsibility to make sure the physicals are up to date and contain all the regulated information as well as to make sure all testing is done in the correct time frames. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. Program Managers will review each individual's physical to ensure compliance with this regulation. 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 management. Documentation of the audit will be maintained by the CPS Director All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1, and #8 07/24/2019 Implemented
2380.111(c)(7)In individual #3's current physical dated 6/28/18 the section titled health maintenance is 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.The physical for individual #3 was revised to correct the blank area on the Health Maintenance area. Beginning immediately all physical examinations will contain an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Any blanks on the form will be filled in with no recommendations beginning made at this time. If the individual would have conditions present that would suggest recommendations should be made (seizure disorder, obesity or other conditions) the Program Specialist will contact the family and ask for clarification from the doctor. Any information received will be added or attached to the individuals physical form. The Program Specialist and staff were retrained on the physical examination regulation. It is the Program Specialists responsibility to make sure the physicals are up to date and contain all the regulated information as well as to continually include information that has changed. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs.. 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 management. Documentation of the audit will be maintained by the CPS Director. All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1 , #6 and #7 07/24/2019 Implemented
2380.113(a)Staff #1 didn't have a current physical located in her record Staff #4 had a physical on 8/12/15 and then again on 9/3/17.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.Individual #1's was contacted to obtain a copy of her most recent physical. IT is the Program Specialist responsibility to ensure that any staff who comes in direct contact with the indivduals for more than 5 days in a 6 month period, has an physical examine within 12 months of employment and then every 2 years afterwards. Beginning immediately HR will scan all current and new employee physicals in Matrix Care (software system) to Program Specialist have the due dates of these documents. It will then be the program specialist responsibility to notify employees 30 days in advance of their due dates and to ensure the physical is completed on time. If the physical is not completed the DSP/Staff will be removed from the schedule. The program Manager will be responsible for checking Matrix Care monthly to ensure compliance. IN addition UCP will begin quarterly audits of their CPS program and will ensure compliance by checking the physical due dates in Matrix Care to ensure they are timely as well as in the individuals Personnel file to ensure a copy exists. 09/30/2019 Implemented
2380.176(a)Filing cabinet on left side of program room had file organizer containing records for individual #4 which were not locked.Individual records shall be kept locked when they are unattended.The document containing individual #4's name and ratio requirements (unlocked document) was immediately removed from the organizer and shredded. It is the responsibility of all staff to ensure that any document that has an individual's full name and protected information is secured when not attended. All staff and supervisors were retrained on this regulation. Beginning immediately all records including empty forms with just names, shall be kept locked when they are unattended. UCP Program Manager are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. In addition UCP will conduct quarterly audits of their CPS programs and if this violation is uncovered the record will immediately be secured and staff retrained. Please see Attachment #1 08/02/2019 Implemented
2380.181(e)(6)REPEAT from 8/13/18: Individual #1's assessment dated on 1/2/19 did not include ability to use or not use poisonous materialsThe assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Individual #1's assessment was revised to include the individual's ability to use or not sure poisonous materials. Beginning immediately all assessments will include this aspect of the regulation. The Program Specialist and all staff were retrained on the assessment regulation. It is the Program Specialists responsibility to create and update an assessment each year including any increase or decrease in all aspects of the individuals programing, and to continually include information that has not changed. This knowledge is for the safety of the individual and will be included in each assessment. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. 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 management. Documentation of the audit will be maintained by the CPS Director. All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1, #4 and #5 07/24/2019 Implemented
2380.181(e)(7)REPEAT from 8/13/18: Individual #1's assessment dated on 1/2/19 did not include knowledge of heat sources and ability to move away from heatThe assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Individual #1's assessment was revised to include the individual's knowledge of the dangers of heat sources and ability to move away from heat. The Program Specialist and all staff were retrained on the assessment regulation. It is the Program Specialists responsibility to create and update an assessment each year including any increase or decrease in all aspects of the individuals programing, and to continually include information that has not changed. This knowledge is for the safety of the individual and will be included in each assessment. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. 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 management. Documentation of the audit will be maintained by the CPS Director. All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1, #4 and #5 07/24/2019 Implemented
2380.181(e)(8)REPEAT from 8/13/18: Individual #1's assessment dated on 1/2/19 did not include ability to evacuate in a fireThe assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.Individual #1's assessment was revised to include the individual's ability to evacuate in a fire. Beginning immediately all assessments will include this aspect of the regulation. The Program Specialist and all staff were retrained on the assessment regulation. It is the Program Specialists responsibility to create and update an assessment each year including any increase or decrease in all aspects of the individuals programing, and to continually include information that has not changed. This knowledge is for the safety of the individual and will be included in each assessment. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. 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 management. Documentation of the audit will be maintained by the CPS Director. All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1, #4 and #5 07/24/2019 Implemented
2380.181(e)(10)Individual #1's assessment dated on 1/2/19 did not include lifetime medical historyThe assessment must include the following information: A lifetime medical history.Individual #1 assessment was revised on 07/09/2019 and included an attached copy of her life time medical history document. . The Program Specialist and DSP's were retrained on the assessment regulation. It is the Program Specialists responsibility to attach the lifetime medical history to each assessment. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs.. 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 management. Documentation of the audit will be maintained by the CPS Director. All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1, #4 and #5. 07/24/2019 Implemented
2380.181(e)(14)Repeat from 8/13/18: Individual #1's assessment dated on 1/2/19 did not include knowledge of water safety/ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Individual #1's assessment was revised to include the individual ability to swim and be around water. Beginning immediately all assessments will include the introduction of the aspect for individuals supported. The Program Specialist and staff were retrained on the assessment regulations. It is the Program Specialists responsibility to create and update an assessment each year including any increase or decrease in all aspects of the individuals programing, and to continually include information that has not changed. This knowledge is for the safety of the individual and will be included in each assessment. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. 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 management. Documentation of the audit will be maintained by the CPS Director and All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1, #4 and #5. 07/24/2019 Implemented
2380.181(f)REPEAT from 8/13/18: Individual #1's record did not include documentation that the assessment dated 1/2/19 was provided to the SC and team members Individual #3's record did not include documentation that the assessment dated 6/22/19 was provided to the SC and team members.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Individual #1's assessment was revised and sent to the SC as required by regulations. All staff were retrained on this regulation and POC on 07/24/2019. It is the responsibility of the Program Specialist to ensure that the individual's team members receive copies of the assessment. Beginning immediately, the program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. The Program Specialist was retrained on the corresponding regulation. UCP Program Managers are responsible for ensuring this practice is completed during their onsite weekly visits to their programs. 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 management. Documentation of the audit will be maintained by the CPS Director. All areas of non-compliance identified through the audit will be corrected within 30 days. Please see Attachments #1, #2 and #5. 07/24/2019 Implemented
Article X.1007REPEAT from 8/13/18 & 9/8/17: Staff #3 was hired on 2/11/19 and her criminal history clearance was disseminated on 2/15/19. OPSA is five days prior or up to date of hire.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.Due to the severity and lack of ability to follow this regulation the last several visits, UCP has contracted with Amerisearch (an outside entity) to complete all criminal history checks prior to having someone start. Ameri-search provides the copy to the HR team who reports that the individual is able to begin work. IT is the Workforce Coordinator's responsibility to complete the check and notify the Program Supervisor and prospective employee when the clearance/check has been completed. No employee will be permitted to start until the crim/check has been initiated. This process will be monitored by the Workforce Coordinators Supervisor and will be monitored during quarterly audits of the CPS programs. All Staff were retrained on this regulation as well as the HR department. Please see attachment #1 and 12. 07/24/2019 Implemented
SIN-00137770 Renewal 08/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(7)Individual #1's ISP was not reviewed for accuracy or content discrepancy. Supervision levels for Individual #1 were not incorporated in the ISP. Individual #1's diet information as detailed in 2380.173(9) were not reported to the SC. Information regarding another provider's services that were terminated were not updated in the plan.The program specialist shall be responsible for the following: Reporting content discrepancy to the SC or plan lead, as applicable, and plan team members.Program Specialist has been retrained in 55 PA Code Chapter 2380.33(b)(7) (Attachment #1) Immediate correction was made to individual #1¿s physical and assessment after clarification with team members, including SC, for accuracy pertaining to special diet instructions, supervision levels, and program service information to ensure consistency across documentation. (See attachments #7, 11) Internal audit tool was distributed to review all documentation sources for content discrepancies and ensure consistency as per information contained in the ISP. (Attachment #12) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.84There was no documentation of the current or previous fire safety inspection.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.Program Specialist has been retrained in 55 PA Code Chapter 2380.84 (Attachment #1) Immediate correction was made to complete the annual onsite firesafety inspection by a firesafety expert, which was completed on 8/21/2018. (Attachment #18) To evidence recent compliance across records, documentation of the date, source and results of the fire safety inspection will be kept. (Attachment #19) Annual Block Training expectations were implemented in March 2018 to ensure that all programs and divisions complete recurring trainings and ensure regulatory compliance at the same time. (Attachment #23) Multi-level checks ensure compliance in the area of onsite fire safety inspections (Attachment #20) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.111(c)(1)Individual #2's physical exam did not include a lifetime medical history.The physical examination shall include: A review of previous medical history.Program Specialist has been retrained in 55 PA Code Chapter 2380.111(c)(1) (Attachment #1) Immediate correction was made to Individual #2¿s record to ensure that physical examination includes a lifetime medical history. PS will ensure that the LMH is found with the physical exam in the medical section as well as with the assessment, rather than just one place (Attachment #15). Attached is another individual¿s physical with LMH attached to evidence recent compliance across records. (Attachment #16) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.111(c)(3)Individual #2's physical exam did not include immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Program Specialist has been retrained in 55 PA Code Chapter 2380.111(c)(3) (Attachment #1) Immediate correction was made to Individual #2¿s physical examination to include immunizations as recommended by the United States Public Health Service, Centers for Disease Control. (Attachment #15) To evidence recent compliance across records, attached is another individual¿s recent physical examination including immunizations as recommended by the CDC. (Attachment #16) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.111(c)(5)Individual #1's 5/30/18 physical exam included a TB test administered on 5/30/18. The results of the TB test were not included with the physical exam. Individual #1's tuberculin test was completed on 3/10/16 and not again until 5/30/18.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Program Specialist has been retrained in 55 PA Code Chapter 2380.111(c)(15) (Attachment #1) Immediate correction was made to Individual #1¿s TB test results to ensure that results read are included with the physical examination to ensure that Tuberculin skin testing is completed with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. (Attachment #17) In order to evidence recent compliance across records, attached is a physical examination indicating TB test results with negative reading, documented correctly by medical personnel. (Attachment #16) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.124(a)Individual #3 was administered Simethicone Drop on 8/6/18, 8/8/18, and 8/10/18. There was no time of administration on the log. There was no time of administration on the August 2018 medication log for the Metoclopram for the same days. There was no time of administration on the June and July 2018 medication logs for the medications provided to Individual #1.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.Program Specialist has been retrained in 55 PA Code Chapter 2380.124(a) (Attachment #1) Immediate correction to Individual #3¿s MAR records was made to ensure that the medication log listing the medications prescribed, dosage, time and date that prescription medications, administered, and the name of the person who administered the prescription medication shall be kept for each individual who does not self-administer medication. Time was entered appropriately for all records. (Attachment #13) Attached is MAR record for Individual #1 showing that medication, dosage, time and date as well as name of person administering is documented on the MAR to evidence recent compliance across records. (Attachment #14) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.173(9)Repeated Violation 9/8/17. Individual #1's Individual Support Plan (ISP) indicated she is to follow a low sodium diet with 2000mg or less, a 48-64oz fluid restriction per day and take a nutritional drink PRN if refusing meals. The assessment indicated a low sodium diet and to cut food into small bite sized pieces with a 64 oz. fluid restriction. The physical exam indicated food needed to be cut into bite sized pieces.Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program Specialist has been retrained in 55 PA Code Chapter 2380.173(9) (Attachment #1) Immediate correction was made to individual #1¿s physical and assessment after clarification for accuracy pertaining to special diet instructions to ensure consistency across documentation. (See attachments #7, 11) Internal audit tool was distributed to review all documentation sources for content discrepancies and ensure consistency as per information contained in the ISP. (Attachment #12) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(e)(1)Individual #1's 4/2/18 assessment did not include needs or preferences.The assessment must include the following information: Functional strengths, needs and preferences of the individual.Program Specialist has been retrained in 55 PA Code Chapter 2380.181(e)(1) (Attachment #1) An addendum was completed to Individual #1¿s assessment to include functional strengths, needs, and preferences of the individual. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects functional strengths, needs, and preferences of the individual to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(e)(4)Individual #1's 4/2/18 assessment did not include supervision needs. The ISP indicated she required 1:1 staffing while at the facility. The ISP indicated line of sight supervision was required during meals due to choking risk.The assessment must include the following information: The individual's need for supervision.Program Specialist has been retrained in 55 PA Code Chapter 2380.181(e)(4) (Attachment #1) An addendum was completed to Individual #1¿s assessment to include supervision needs, specifically that she required 1:1 staffing while at the facility as well as line of sight supervision during meals due to choking risk, as per ISP. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects supervision needs of the individual as per ISP to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(e)(6)Individual #1's 4/2/18 assessment did not include her ability to safely use or avoid 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.Program Specialist has been retrained in 55 PA Code Chapter 2380.181(e)(6) (Attachment #1) An addendum was completed to Individual #1¿s assessment to include her ability to safely use or avoid poisonous materials when in the presence of such materials. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects individual¿s ability to safely use or avoid poisonous materials when in the presence of such materials as per ISP to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(e)(7)Individual #1's 4/2/18 assessment did not include her knowledge of heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Program Specialist has been retrained in 55 PA Code Chapter 2380.181(e)(7) (Attachment #1) An addendum was completed to Individual #1¿s assessment to include the individual¿s knowledge of the danger of heat sources and her ability to sense and move away quickly from heat sources which exceed 120F and are not insulated, as documented in the ISP. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects the individual¿s knowledge of the danger of heat sources and her ability to sense and move away quickly from heat sources which exceed 120F and are not insulated as per ISP to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(e)(8)Individual #1's 4/2/18 assessment did not include her ability to evacuate in the event of an emergency.The assessment must include the following information: The individual's ability to evacuate in the event of a fire.Program Specialist has been retrained in 55 PA Code Chapter 2380.181(e)(8) (Attachment #1) An addendum was completed to Individual #1¿s assessment to include the individual¿s ability to evacuate in the event of an emergency, as documented in the ISP. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects individual¿s ability to evacuate in the event of an emergency, as per ISP to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(e)(9)Individual #1's 4/2/18 assessment did not include her functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.Program Specialist has been retrained in 55 PA Code Chapter 2380.181(e)(9) (Attachment #1) An addendum was completed to Individual #1¿s assessment to include documentation of the individual¿s disability, including the individual¿s functional and medical limitations, as documented in the ISP. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects documentation of the individual¿s disability, including the individual¿s functional and medical limitations, as per ISP to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(e)(14)Individual #1's 4/2/18 assessment did not include her knowledge of water safety or ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.Program Specialist has been retrained in 55 PA Code Chapter 2380.181(e)(14) (Attachment #1) An addendum was completed to Individual #1¿s assessment to include the individual¿s knowledge of water safety and/or ability to swim, as documented in the ISP. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects the individual¿s knowledge of water safety and/or ability to swim, as per ISP to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.181(f)There was no documentation to indicate Individual #1's 4/2/18 assessment was sent to plan team members.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Program Specialist has been retrained in 55 PA Code Chapter 2380.181(f) (Attachment #1) Current Program Specialist distributed the 4/2/18 assessment to all team members as an immediate corrective action and as best practice in the case that it was truly not sent in April. (Attachment #9) Attached is another assessment distribution letter, indication provision of the assessment to the SC and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP, to evidence recent compliance across records. (Attachment #10) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.183(4)Individual #1's ISP did not include supervision needs while at the facility or in the community. The ISP indicated 1:1 support was provided however, there was no plan to reduce the intensive staffing.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.Program Specialist has been retrained in 55 PA Code Chapter 2380.183(4) (Attachment #1) Individual #1¿s assessment was revised to include supervision needs while at the facility or in the community as per ISP as well as factors to be in considered to reduce intensive staffing; this protocol includes the current level of independence and method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. (Attachment #7) Attached is another assessment dated 8/8/18 that reflects supervision needs while in the facility and community as per the individual¿s ISP to evidence recent compliance across records. (Attachment #8) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.186(b)Individual #1's 5/5/18 ISP review was not signed or dated by the program specialist or Individual #1.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Program Specialist has been retrained in 55 PA Code Chapter 2380.186(b) (attachment #1) As immediate correction, Program Specialist has completed and signed to review of 5/15/18 ISP review (Attachment #2). Program Specialist has provided recent Quarterly Review dated 8.15.18 to evidence recent compliance across records for program specialist and individual signatures and dates confirming review of quarterly report (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) 09/04/2018 Implemented
2380.186(d)There was no documentation to indicate Individual #1's 5/5/18 ISP review was 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.Program Specialist has been retrained in 55 PA Code Chapter 2380.186(d) (attachment #1) Program Specialist will ensure that ISP Reviews are distributed to all team members within 5 days of quarterly report being written as best practice. Team members will be determined by ISP contacts listed, service providers including participants of IDT meetings and recipients of original meeting invites. Individual #1¿s ISP review was distributed to all members (Attachment #5) Program Specialist has provided Quarterly Review distribution letter dated 8.15.18 to evidence recent compliance across records distribution of quarterly report to all team members (attachment #6). Templates were provided to PS for ISP Review Sign Sheets to include declination as best practice (Attachment #7). Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
2380.186(e)An option to decline Individual #1's ISP reviews was not offered to plan team members.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Program Specialist has been retrained in 55 PA Code Chapter 2380.186(e) (Attachment #1) Declination letter was sent to Individual #1¿s team members as immediate corrective action (Attachment #5). ISP sign sheets were revised to include the option to decline (Attachment #6). It is the Program Specialist¿s responsibility to provide the recipients of the ISP reviews the option to decline receiving them. ISP Review declination option for recent quarterly review is attached to evidence recent compliance across records (Attachment #6) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
Article X.1007Repeated Violation - 9/8/17. United Cerebral Palsy 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 4/30/18. A criminal history check was requested on 5/4/18.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.Program Specialist has been retrained in 55 PA Code Chapter Article X.1007) (Attachment #1) 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 #20, 21). To evidence recent compliance across records, attached is recent PATCH/Criminal History Record for new employee, completed prior to date of hire. (Attachment #22) Quarterly audits of individual records will be completed within the program with agency-approved audit worksheets to ensure compliance in this area. (Attachment #4) 09/04/2018 Implemented
SIN-00118872 Renewal 09/08/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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.1007United 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
SIN-00194257 Renewal 10/19/2021 Compliant - Finalized
SIN-00099465 Initial review 08/15/2016 Compliant - Finalized