| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Services Worker #1, date of hire 3/3/15, did not have Pennsylvania criminal history record check. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Valley Community Services will ensure all prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the persons date of hire will have a Pennsylvania criminal history check completed. An email with documentation of direct support working #1 has been sent to the BHSL contact for review. The licensor reviewed information at a satellite office, in which the employees files were transported. Direct Support Worker #1 Pennsylvania criminal history record check was not present in the employees file at that time. The "Date of the Request" was 2/24/2015 at 1:40:00 pm. Direct Support Worker #1 date of hire is 3/3/2105.[The complete criminal background check for DSW #1 was submitted to the on 1/29/16. Immediately, CEO will review all staff records to ensure all staff have a complete PA criminal history check as required. CEO will review all criminal record checks for all new staff to ensure completion, compliance and timeliness. Documentation of review by the CEO shall be kept. (AS 2/25/16)] |
10/15/2015
| Implemented |
| 6400.46(g) | The two most recent fire safety trainings for Direct Service Worker #2 were 4/24/14 and 5/13/15. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | Valley Community Services will ensure all program specialists and direct support professionals are trained annually by a fire safety expert. The operations director will retrain all program managers on regulation 46(g) prior to October 22, 2015. To ensure ongoing compliance, the Quality Assurance Department will conduct bi-annual audits to ensure proper documentation. [Immediately, CEO or designated staff will develop and implement a tracking system to ensure all required trainings including fire safety training are completed timely. (AS 2/25/16)] |
10/22/2015
| Implemented |
| 6400.141(c)(7) | The gynecological examination on 6/3/15 and the physical examination on 4/8/15 for Individual #1 do not include a breast examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Valley Community Services will ensure gynecologic examinations include a breast examination. The information on the 6/3/15 appointment did not clarify a breast examination was completed. The operations director will retrain program managers on regulation 141(C)(7) prior to October 22, 2015. They will ensure this information is addressed in the documentation. Individual #1 is no longer with Valley Community Services. To ensure ongoing compliance, the Quality Assurance Department will conduct bi-annual audits to ensure proper document. [Immediately, CEO or designated staff person will review all individuals' current physical examinations to ensure all required elements are present and obtain if needed. For 1 year from receipt of the plan of correction, the CEO or designated staff person will review all completed physical examination to ensure all required information is present. Documentation of reviews and trainings shall be kept. (AS2/25/16)] |
10/22/2015
| Implemented |
| 6400.194(b) | The restrictive procedure committee review did not include positions of the committee; therefore, complaince could not be measured. | The restrictive procedure review committee shall include a majority of persons who do not provide direct services to the individual.
| Valley Community Services' restrictive procedure review committee consists of only community members. There are no employees of Valley Community Services that sit on the committee. They do not provide direct nor non-direct services to any individual residing at Valley Community Services. Only William A. Janes, Psychologist and/or designee, who presents the information and does not approve or deny any implementation of restricted procedure, are employed by Valley Community Services. An email of the minutes from the committee from June 18, 2015, where individual #1 plan was reviewed and approved has been sent for review. Committee members are listed. Upon request, a redacted list of employees can be submitted to prove human rights committee members are not employees. [Documentation of the restrictive procedures review committee will show who is providing services and who is not providing services to the individual, will be maintained by the CEO, so compliance is able to be measured.(AS 2/25/16)] |
10/15/2015
| Implemented |
| 6400.195(d) | Individual #1's restrictive procedure plan was not signed by a program specialist on 12/15/14, 3/16/15 and 3/30/15. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| Individual #1's restrictive procedure plan was signed by the program specialist on 12/15/14, 3/16/15 and 3/30/15. Prior to signing the plan, the program specialist copied the plan to place in the travel book and use as a training tool for the staff. The Program Director will retrain the program specialist on 195(d) prior to October 22, 2015. The program specialist will only make copies of plans for training purposes with all signatures present. To ensure no further infractions, the operations director will periodically check the travel book to verify information is current. [Documentation of trainings and aforementioned periodic checks shall be kept and reviewed by the CEO at least quarterly to ensure competition and required signatures. (AS 2/25/16)] |
10/22/2015
| Implemented |
| 6400.195(e)(1) | Individual #1's restrictive procedure plan did not include the specific behavior to be addressed and the suspected antecedent or reason for the behavior, the single behavioral outcome desired stated in measurable terms, types of restrictive procedures that may be used and the circumstances under which the procedures may be used, the amount of time the restrictive procedure may be applied, not to exceed the maximum time periods or physical problems that require special attention during the use of restrictive procedures. | The restrictive procedure plan shall include: The specific behavior to be addressed and the suspected antecedent or reason for the behavior.
| Individual #1's restrictive procedure plan has and continue to include: The specific behavior to be addressed and the suspected antecedents or reason for the behavior. Valley Community Services will submit Individual #1's restrictive procedure plan to the BHSL contact with all sections.[Restrictive procedures for Individual #1 were submitted to the department on 2/17/16. (AS 2/24/16)] |
10/15/2015
| Implemented |
| 6400.195(g) | Individual #1's record did not include a copy of the restrictive procedure plan. | Copies of the restrictive procedure plan shall be kept in the individual's record.
| Valley Community Services' will ensure copies of the restrictive procedure plan are kept in the individual's record. Upon arrival, staff was asked for the program file for Individual #1. The individuals record was not presented to the BHSL surveyor; instead staff inadvertently provided the individual "travel book". The Quality Assurance director will retrain all program managers and program specialists on regulation 195(g) prior to November 1, 2015, ensuring all information is complete, current and accurate in each of the individual's "travel book". The program managers will train all staff on the permanent chart versus "travel books", which although current and accurate, is not the file(s) that BHSL would be requiring during unannounced visits. This training will be completed prior to November 16, 2015. To ensure compliance, operation directors will quarterly visit each home on a random schedule an ensure staff furnish the permanent record, when requested. |
11/01/2015
| Implemented |