Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The basement door did not shut completely unless force was used to slam it shut. | Floors, walls, ceilings and other surfaces shall be in good repair. | November 8, 2018- All Program Specialists were trained on their responsibilities that floors, walls, ceilings and other surfaces shall be in good repair. A training record was signed indicating their attendance and understanding.
November 20, 2018- A maintenance request was completed to install a handle on the middle of the basement door to facilitate the ease of closing it. The handle has been installed. All agency homes have been reviewed and evaluated and are currently in compliance.
November 20, 2018- A monthly review will be completed by a member of the safety committee evaluating the homes floors, walls, ceilings, and other surfaces to ensure they are all in good repair. The process is completed at each home on a monthly basis. |
11/20/2018
| Implemented |
6400.73(a) | The steps leading to the basement on the outside of the home were not equipped with a handrail on the top 5 steps. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | November 8, 2018- All Program Specialists were trained on their responsibilities that each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A training record was signed indicating their attendance and understanding.
November 20, 2018- A maintenance request was completed to install a handrail to the steps leading to the basement. The handrail has been installed. All agency homes have been reviewed and evaluated and are currently are in compliance.
November 20, 2018- A monthly review will be completed by a member of the safety committee evaluating the homes ramps, interior stairways, and outside steps exceeding two steps needed for a well secured handrail. The process is completed at each home on a monthly basis. |
11/20/2018
| Implemented |
6400.103 | The written emergency evacuation plan did not include the means of transportation. The plan indicated staff were going to transport the individual but did not explain how; i.e. staff vehicle, personal vehicle, company vehicle, etc. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| November 8, 2018- All Program Specialists were trained on their responsibilities that there shall be written emergency evacuation procedures that include individual and staff responsibilities, mean of transportation, and an emergency shelter location. A training record was signed indicating their attendance and understanding. The agency Emergency and Removal Transfer Plan template has been revised to include means of transportation. This new form is a template and is prepopulated to ensure compliance when referencing means of transportation.
November 12, 2018- In all agency homes the Program Specialist updated all Emergency and Removal Transfer plans. They have been verified by the ID Director to be correct and in compliance. |
11/12/2018
| Implemented |
6400.112(i) | A smoke detector wasn't sent off for every fire drill. Sometimes the smoke detector was set off in 311 Fry Drive home that is attached to 309 Fry Drive (a separate licensed home) and the smoke detectors are inner connected. | A fire alarm or smoke detector shall be set off during each fire drill. | All Program Specialists were trained on their responsibilities that a fire alarm or smoke detector shall be set off during each fire drill. A training record was signed indicating their attendance and understanding. The agency fire drill record has been revised with instructions stating that ¿Interconnected detectors at 309/311 Fry Drive and
1259 A/B Old Boalsburg Road must have a smoke detector set off at each home during each fire drill.¿
November 13, 2018- A fire drill was conducted at 309 and 311 Fry Drive with a smoke detector being set off at each location during the fire drill. All fire drill records were reviewed to verify that a fire alarm or smoke detector was set off during each fire drill. All agency fire drill records have been reviewed by the ID Director to verify that a fire alarm or smoke detector is set off during each fire drill at each home. The ID Director will review all fire drill records at each home to ensure compliance on a quarterly basis. |
11/13/2018
| Implemented |
6400.113(a) | Individual #1 moved into the residential home located at 309 Fry Drive on 7/18/18 but did not receive fire safety training for this home location upon moving into the home. The individual last received fire safety training at Old Boalsburg Rd on 3/29/18. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | November 8, 2018- All Program Specialists were trained on their responsibilities that an individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. A training record was signed indicating their attendance and understanding.
October 29, 2018- Individual #1 last received fire safety training on 3/29/18 at her prior home. She moved into her new home on 7/18/18 and did not receive fire safety training until 10/29/18. In addition, a client site safety inspection has been developed and will be used for all new admissions. All Program Specialists have verified that all individuals are up to date with fire safety.
November 20, 2018- All Program Specialists will coordinate/review fire safety training at least annually for all individuals, including new admissions and/or individuals who transfer within the agency. |
12/05/2018
| Implemented |
6400.141(c)(11) | Individual #1's 4/30/18 physical examination form did not include health maintanence needs. The field was left blank. The department clarified that blanks of regulatory requirements on the physical form would result in a violation. | 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. | November 8, 2018- All Program Specialists were trained on their responsibilities that 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. A training record was signed indicating their attendance and understanding.
November 6, 2018- Individual #1¿s physical exam was returned to the physician to complete the health maintenance needs, the medication review, and the need for bloodwork at recommended intervals, which was left blank. The required info was completed by the physician. All physicals have been reviewed by the Program Specialists and verified to be completed correctly and in compliance.
November 20, 2018- All Program Specialists will review all completed physicals when returned to ensure that all spaces on the physical are completed/responded to. |
12/26/2018
| Implemented |
6400.142(f) | According to Individual #1's medication lists, they have been prescribed Prevident Dental Rinse to use on Sundays before bed since 3/16/16. The individual's dentist also included on their 5/17/18 dental examination form, to brush 2x/day, floss 1x/day with manual floss followed by water pik at night. The individual was not independent with dental hygiene and there wasn't a written plan for dental hygiene. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | November 8, 2018- All Program Specialists were trained on their responsibilities that an individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. A training record was signed indicating their attendance and understanding.
November 15, 2018- Individual #1 had their ISP updated to reflect current levels of assistance needed, including the use of a dental rinse and the process. The use of Prevident Dental Rinse on Sundays before bed has been added, including brushing 2x/day, floss 1x/day with manual floss, followed by water pik at night. The plan was also updated to include Individual #1 is independent in dental hygiene. All current dental hygiene plans have been reviewed by the Program Specialists and are currently in compliance.
November 2, 2018- The quarterly review form has been revised to include a ¿Dental Hygiene Plan Review¿ section of the quarterly report. All ISP¿s have been verified by the Program Specialists to be in compliance. Program Specialists will review all sections of the ISP in each quarterly report which includes dental hygiene plan review. |
11/15/2018
| Implemented |
6400.144 | Individual #1's therapy note indicated the visit scheduled for 3/21/18 was canceled due to inclement weather and the next appointment was scheduled for 3/28/18. The individual was not seen again until 4/4/18 with no indication of why the appointment on 3/28/18 was missed. The individual's therapy appointment on 6/20/18 indicated he/she was to be seen again on 6/27/18. The individual did not return to his/her therapist until 7/11/18 with no indication of why the appointment was late.
---Individual #1 was seen by their dentist on 8/8/18 for a cleaning and the dentist indicated "regular 6 month recall visits, #5 root canal - see if ma covers it, if not we will do it here." There was no documentation that this was addressed with insurance or the dentist for a follow up root canal at the time of licensing on 10/24/18. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| November 8, 2018- All Program Specialists were trained on their responsibilities that all health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. A training record was signed indicating their attendance and understanding.
November 14, 2018- Individual #1 had a therapy note indicating a visit scheduled for 3/21/18 was cancelled due to inclement weather and the next appointment was scheduled for 3/28/18. She was not seen on 3/28/18 due to the counselor being out of the office. The counselor sent a letter to SFI stating that they were cancelling the appointment. Individual #1 had a therapy appointment scheduled for 6/20/18 and was to be seen again on 6/27/18. This appointment did take place as scheduled on 6/27/18 and a counseling form was completed at the appointment for verification. Individual #1 was scheduled for and received a root canal on 11/5/18 and a dental form was completed at the appointment for verification. Program Specialists will continue to arrange for and provide all health services that are planned or prescribed for individuals. All Program Specialists have reviewed and verified that all health services are currently in compliance. |
11/14/2018
| Implemented |
6400.164(a) | Individual #1's physician indicated that over the counter Ibuprofen or equal medication can be used for pain. The over the counter medication label for Ibuprofen indicated "if pain or fever doesn't respond to 1 tablet, 2 caplets may be used" but this wasn't indicated on the medication log.
--The individual's over the counter approved Pepto-Bismol indicated to "shake well, 1 dose (30ml or 2 tbsp.) every half to one hour as needed, don't exceed 8 doses in 24 hours use until diarrhea stops but no more than 2 days." The medication logs for the year only indicated to administer "1 dose (30ml or 2 tbsp) every ½ hour to 1 hour as needed by mouth."
--Ibuprofen was administered on 4/4/18 and only "10" was indicated on the medication log; No AM or PM indicated for the actual time of administration.
--Saline nasal spray was administered on 1/29/18 but no time of administration was recorded. Only "245" was indicated on the medication log; no AM or PM was included to indicate time of administration.
--The Individual's Sudafed over the county medication label indicated to administer "1 tab ever 12 hours, don't take more than 2 tabs in 24 hours, tabs=120mg." The medication log indicated to "take 1 tablet every 12 hours don't take more than 2 in 24 hrs."
--Clear eyes maximum itchy eye relief over the counter medication label indicated to "instill 1 to 2 drops in affected eyes up to 4x daily." The corresponding medication logs indicated "clear eyes instill 2 drops into affected eyes up to 4x daily."
--Saline Nasal Spray over the counter medication label indicated to "squeeze twice in each nostril as needed." The medication log indicated to "use one spray in each nostril as needed for nose bleeds and dryness." | 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. | November 8, 2018- All Program Specialists were trained on their responsibilities that 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. A training record was signed indicating their attendance and understanding.
November 20, 2018- Individual #1¿s over the counter medication administration record was corrected to include all instructions for the following OTC medications: Ibuprofen, Pepto Bismol, Sudafed, and saline nasal spray. All OTC medications and medication administration logs have been reviewed and verified by the Program Specialists to be correct and in compliance. All Program Specialists will review over the counter medications and medication administration records monthly to ensure all instructions are written correctly on the medication administration record. |
11/20/2018
| Implemented |
6400.167(b) | Individual #1 was prescribed Naproxen 250mg twice a day for 5 days then as needed. The medication was initialed as administered for 5.5 days from 8pm on 11/16/17 to 8pm on 11/21/17.
--The individual did not have a doctor's order or approved over the counter order for clear eyes maximum itch relief and it was administered on 8/26/18, 2/17/18, and 1/8/18.
--The individual did not have a doctor's order or approved over the counter order for saline nasal spray and it was administered on 2/7/18, 2/20/18,1/29/18, 12/1/17, 12/4/17, 12/10/17 and 12/29/17.
--The individual did not have a doctor's order or approved over the counter order for fluticasone prop 50mcg spray. The medication was administered once daily up until 1/31/18. The medication wasn't administered daily after 1/31/18. There is no original order or a discontinue order in the individual's record. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | November 8, 2018- All Program Specialists were trained on their responsibilities that prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician¿s assistant. A training record was signed indicating their attendance and understanding.
November 17, 2018- Individual #1 obtained approval to use Clear Eyes and saline nasal spray as an OTC. This is documented June 19, 2017. Individual #1 does have an original order for Fluticasone Prop 50mcg spray from Dr. Victoria Devan. There is not a discontinuation order because they still receive it daily. The Fluticasone Prop 50mcg spray is documented on Individual #1¿s medication administration record from 2/1/18-present. The medication is administered daily as prescribed. |
11/20/2018
| Implemented |
6400.181(e)(3)(i) | Individual #1's 4/16/18 assessment did not include the individual's current level of performance in functional skills. This section was blank on the assessment. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | November 8, 2018- All Program Specialists were trained on their responsibilities that the assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. A training record was signed indicating their attendance and understanding.
November 15, 2018- The agency assessment template was revised to allow a place to respond to ¿Acquisition of Functional Skills.¿ The revision and addition of this expanded space will help to make it more clear that it is a section to be addressed. Individual #1¿s assessment has been updated to include information on their current level of performance and progress in the area of ¿Acquisition of Functional Skills.¿ All assessments agency wide have been reviewed by the Program Specialists to ensure compliance. Program Specialists will review assessment content in the quarterly reports. |
11/15/2018
| Implemented |
6400.181(e)(13)(vii) | REPEAT from 9/27/17 annual inspection and 2016 annual inspection: Individual #1's 4/16/18 assessment indicated they could not handle any amounts of money. However according to the agency, the individual handles $20 independently. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| November 8, 2018- All Program Specialists were trained on their responsibilities that the assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. A training record was signed indicating their attendance and understanding.
November 14, 2018- Individual #1 had their assessment updated to reflect their progress over the last 365 calendar days to include their current level in the financial independence area. All assessments have been reviewed and verified by the Program Specialists to be correct and in compliance. SFI¿s annual assessment form has been updated to include any changes made in the areas of progress and growth should be verified for accuracy in the individual¿s current ISP. All Program Specialists will review assessments and ISP for content accuracy. |
11/14/2018
| Implemented |
6400.181(f) | Individual #1's team members that were not sent a copy of the individual's 4/6/18 assessment were their father and CSG day program. | (f) The program specialist shall provide the assessment to the SC, 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).
| November 8, 2018- All Program Specialists were trained on their responsibilities that the program specialist shall provide the assessment to the SC, 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 (relating to development, annual update and revision of the ISP). A training record was signed indicating their attendance and understanding.
November 14, 2018- Individual #1¿s assessment was sent to all plan team members.
November 8, 2018- The annual assessment cover letter has been revised to include a CC that references all team members. This revision will help alert the Program Specialists to include all team members to receive the assessment at 30 days prior to the ISP meeting. All assessment dates have been reviewed and verified to have been sent to all plan team members at least 30 calendar days prior to the ISP meeting by the Program Specialist. All Program Specialists will review and ensure team members receive the assessment as appropriate. |
01/20/2019
| Implemented |
6400.183(5) | The protocol to address Individual #1's social, emotional and environmental needs in relation to the symptoms of his/her diagnosed psychiatric illness that was included in their Individual Support Plan (ISP) didn't include the individual's recommendations they made throughout the year. Those recommendation were to practice deep breathing with staff, having staff check on the individual at night to make sure he's/she's ok, asking the individual if he/she is ok throughout the day, and seeing if his/her nails are clipped so he/she won't scratch himself/herself. | The ISP, including annual updates and revisions under § 6400.186 (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. | November 8, 2018- All Program Specialists were trained on their responsibilities that the ISP, including annual updates and revisions (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. A training record was signed indicating their attendance and understanding.
November 2, 2018- Individual #1¿s quarterly report ending on 10/9/18 and sent out to all team members on 11/2/18, included a revision to the protocol to address the social, emotional, and environmental needs of the individual (SEEP). The revision included recommendations Individual #1 and their therapist had discussed throughout the year.
November 9, 2018- The ISP of Individual #1 was revised in the Behavior Support Plan section under the protocol to address the social, emotional, and emotional needs of Individual #1. The plan includes recommendations they made throughout the year. All ISP¿s have been reviewed and verified by the Program Specialist to be in compliance.
November 2, 2018- The quarterly review form has been revised to include any recommendations made by the individual in addition to the therapist notes. Program Specialists will review all sections of the ISP for accuracy. |
11/09/2018
| Implemented |
6400.185(b) | --Individual #1's Individual Support Plan (ISP) indicates knives and scissors need locked up due to the individuals threats of self-harm. There were 5 scissors unlocked and easily accessible in the staff office. Staff indicated that the staff office isn't locked when the individual is home.
--The Individual's ISP also indicates that they can carry out small financial transactions at stores, needs help with budgeting, and she/he and staff have to go cash a weekly check for $20. It doesn't indicate the individual can handle up to $20 and the individual is given the $20 to spend independently currently. | The ISP shall be implemented as written. | November 8, 2018- All Program Specialists were trained on their responsibilities that the ISP shall be implemented as written. A training record was signed indicating their attendance and understanding.
November 15, 2018- A new locking file cabinet was purchased to ensure that knives and scissors are locked up due to Individual #1¿s threats of self-harm. All knives and scissors were moved to this locking file cabinet and a memo went out to all current staff instructing them of this procedure. Individual #1¿s ISP Financial Management section has been revised to reflect that she can handle up to $20 independently. All ISP¿s have been verified by the Program Specialists to be in compliance.
November 15, 2018- All staff will be trained on implementing the ISP as written. This training will be completed during a staff members on site training and will be verified by the Program Specialists. |
11/15/2018
| Implemented |
6400.186(a) | REPEAT from 9/27/17 annual inspection: Individual #1's Individual Support Plan (ISP) reviews covering the quarterly period from 1/20/18-4/19/18 wasn't completed (signed/dated) until 5/8/18, late. The individual's 2/8/18 ISP review reviewed the period from 10/20/17 to 1/19/18, therefore completed late. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | November 8, 2018- All Program Specialists were trained on their responsibilities that the Program Specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. A training record was signed indicating their attendance and understanding.
November 2, 2018- A three month review was completed for the review period 7/20/18 to 10/19/18. The three month review was also signed/dated and sent to the team on 11/2/18, which is within the required 15 days. All Program Specialists have reviewed and verified that all quarterly reviews are currently in compliance.
November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports to the Assistant Director of ID for verification of completion and distribution within 15 days after the three month review period ends, allowing time for a reminder notification to be sent to the Program Specialists. |
11/08/2018
| Implemented |
6400.186(c)(2) | Individual #1's 10/23/18, 8/3/18, 5/8/18 and 2/8/18 Individual Support Plan (ISP) reviews didn't review if the individual used any of his/her unsupervised time in the community. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | November 8, 2018- All Program Specialists were trained on their responsibilities that the ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. A training record was signed indicating their attendance and understanding.
November 2, 2018- The quarterly review form has been revised to include ¿Supervision Plan Review¿ in the ¿Review of all Sections of the ISP¿ section of the quarterly report. All ISP reviews have been verified by the Program Specialists to be in compliance. Program Specialists will review all sections of the ISP in each quarterly report which includes Supervision Plan Review.
November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports to the Assistant Director of ID for verification of completion and distribution within 15 days after the three month review period ends, allowing time for a reminder notification to be sent to the Program Specialists. |
11/08/2018
| Implemented |
6400.186(d) | REPEAT from 9/27/17 annual inspection: Individual #1's 10/23/18, 8/3/18 and 5/8/18 Individual Support Plan (ISP) reviews were not sent to day program, job coach and the individual's father whom are all team members. The individual's 2/8/18 ISP review was only sent to the supports coordinator and not to the individual or any other team member. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | November 8, 2018- All Program Specialists were trained on their responsibilities that the program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. A training record was signed indicating their attendance and understanding.
November 2, 2018- Individual #1 had an ISP review on 10/19/18 and it was sent out to all team members on 11/2/18.
November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports and cover letters to the Assistant Director of ID for verification of completion and distribution to all team members within 30 days after the ISP review meeting. All ISP¿s have been verified by the Program Specialists to be in compliance. |
11/08/2018
| Implemented |
6400.186(e) | The individual's program specialist did not offer the individual's father, supports coordinator, day program or job coach the option to decline the individual's Individual Support Plan (ISP) review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | November 8, 2018- All Program Specialists were trained on their responsibilities that the program specialist shall notify the plan team members of the option to decline the ISP review documentation. A training record was signed indicating their attendance and understanding.
November 2, 2018- The Program Specialist has notified all plan team members of the option to decline the ISP review documentation via the quarterly ISP review cover letter when it was sent out. Individual #1 had an ISP review ending 10/19/18 and it was sent out to all team members on 11/2/18. All ISP reviews have been verified by the Program Specialists to be in compliance.
November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports and cover letters to the Assistant Director of ID for verification of completion and distribution to all team members. The cover letter includes the following statement, ¿As a member of _______¿s team, you have the right to decline receiving the ISP review documentation.¿ |
11/08/2018
| Implemented |
6400.216(a) | The individual's records were kept in unlocked and accessible I'm the staff office. According to staff, the staff office isn't locked when the individual is home. | An individual's records shall be kept locked when unattended.
| November 8, 2018- All Program Specialists were trained on their responsibilities that all individuals records shall be kept locked when unattended. A training record was signed indicating their attendance and understanding.
November 15, 2018- A new locking file cabinet was purchased to ensure that the individual¿s records are kept locked when unattended. All records were moved into this locking file cabinet and a memo went to all current staff instructing them of this procedure. All Program Specialists have reviewed and verified that individuals records are kept locked when unattended and are in compliance.
November 15, 2018- All staff will be trained on keeping all individuals records locked when unattended. This training will be completed during a staff member¿s on-site training and will be verified by the Program Specialists. |
11/20/2018
| Implemented |