| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1 requires total assistance from Valley Community Services, to manage their finances and assistance to manage their personal property. The agency is the individual's representative payee. The individual's current property record states they have a record player and records in their possession, however these items are not in their possession. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | During the investigation, Individual #1 stated that they threw the item away. Individual #1 was asked if they wanted the record player replaced and decided they wanted the funds instead. As result of the investigation, all staff are to try to be aware of Individual #1s propensity to throw away items and to list the item in the electronic record. The behavioral specialist has completed a behavior plan to address Individual #1's necessity to remove items they requested and throw them away. See Attachment 3. The information has been requested to be added to the ISP. Program Managers were trained on 6400.22(d)(1) by the Central Region Operations Director on February 23, 2023, and stressed the importance of updating the personal property when individuals choose to dispose of any items. Outline and attendance record has been submitted for review. |
02/23/2023
| Implemented |
| 6400.22(e)(1) | Individual #1 requires total assistance from Valley Community Services, to manage their finances. The agency is the individual's representative payee. Referenced in 6400.43(b)(3) of this report, the agency failed to keep an up-to-date financial record of all the individual's funds located at the home and when the home received disbursements of funds for the individual and made transactions.
According to special purchase requests, the individual had large sums of money coming to the home in February 2022: $300, May 2022: $500 and December 2022: $500. The date of when the monies was recorded on the individual's financial records and available to the individual in the home was not recorded. The daily balance of funds left from the special purchase money was never recorded as the total balance of money available in the home. Additionally, it was reported to the Department that the amount of funds left over from the three special purchase requests, was either returned to the individual or the individual's representative payee. The record of when the balance from those funds was returned to the individual or their representative payee account, was not documented or not documented until monthly later. For example, staff purchased items for Individual #1 using the individual's funds on 12/16/22 and 12/21/22 totaling $465.36. There is no record that the home returned the remaining $34.64 to the individual or their financial account.
According to the individual's EBT food stamp monthly ledger, they spent $92.20 on 7/4/22. The home recorded this as an addition to the total amount left on the card and not a deduction. This error was never caught. As of 1/20/23 there is no corrected amount of the total amount of funds on the EBT card or accessible to the individual. The total balance left in the account was never tracked or recorded daily or for the end of the month balance in July and August 2022. There are no monthly tracking ledgers for the EBT food stamp card for January 2023. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | The Safeguarding Funds policy has been updated. All Special Purchases will continue to document on the forms as required; however, the amount of funds received will also be documented on the individual's petty cash log. As items are purchased, the location and amount will be placed on the petty cash log. If funds are at an amount uncomfortable to be left in the home, a withdrawal will be listed, and the funds will be returned to the representative payee to be deposited back into the individual's account. If the individual chooses to keep the money at home, it will be listed on the Special Cash forms.
Review of the changes to Safeguarding Funds were completed by the Representative Payee on February 22, 2023 with Program Managers and Program Specialists. The policy, outline and attendance record were sent for review.
Individual #1 documentation on 7/4/22 was accurately posted on the EBT form. The amount of $92.20 was additional funds added each month during the pandemic. ODP has sent out Announcement stating the additional funds will no longer be available after February 2023.
The EBT documentation will be uploaded to the secured SharePoint by the 5th of each month, starting March 2023. The form and receipts will be placed in the individual's folder. The representative payee will ensure that all paperwork is obtained and is accurate by the 10th of each month. If there are discrepancies, an email will be sent to the Program Manager and cc: Program Specialists. Adjustments will be required and uploaded. The revised policy and step-by-step instructions were trained on February 22, 2023, by the Representative Payee with the Program Managers and Program Specialists. The outline, policy, and attendance record have been submitted for review. |
02/22/2023
| Implemented |
| 6400.22(e)(3) | Individual #1 requires total assistance from Valley Community Services, to manage their finances. The agency is the individual's representative payee. The home manages the individual's food stamp (EBT) card and all purchases. The home does not have receipts for any purchases made with the EBT car for 2022 and 2023. According to the agency's EBT expenditure reports, approximately $4,788.74 was used from the individual's EBT card from January 2022 to December 2022 to make purchases. There are no records of the purchases. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Individual #1s receipts from EBT purchases are unavailable. The EBT documentation will be uploaded to the secured SharePoint by the 5th of each month, starting March 2023. The form and receipts will be placed in the individual's folder. The representative payee will ensure that all paperwork is obtained and is accurate by the 10th of each month. If there are discrepancies, an email will be sent to the Program Manager and cc: Program Specialists. Adjustments will be required and uploaded. The revised policy and step-by-step instructions were trained on February 22, 2023, by the Representative Payee with the Program Managers and Program Specialists. The outline, policy, and attendance record have been submitted for review. |
02/22/2023
| Implemented |
| 6400.43(b)(3) | The agency has been using electronic medication administration records since 12/1/2022 to document medication administration to individuals identified as not being able to complete this task independently. During the 1/17/2023 inspection, the agency reported they do not have a medication administration policy applicable to the electronic mar system and documentation to ensure proper health and safety protection of individuals with medication management on the electronic system. Referenced in 6400.166(b) of this report, Individual #1's electronic mar was not completed to indicate proper medication administration on two occasions since the electronic implementation. The agency does not have a medication administration policy that includes how to address how staff are to administer and document medications if the electronic system is not operable during medication administration times.
The agency failed to adhere to their Safeguarding Individual Funds financial policy, thus occasions occurred in 2022 where Individual #1's funds and property were not protected. According to the financial policy, if a request for special purchases is made to spend individuals' money, a special purchases expense form will be completed on a daily basis with a detailed record of all purchases made to date. The forms will be kept until the funds are spent. The special purchases expense form must be kept in balance at all times. Purchases must be made within two weeks after receiving the check. The program manager will complete expenditure form for special purchases, attach original receipts and any money not spent will be returned to the representative payee. Special purchase requests were made on 2/3/22 for $300 and 5/16/22 for $500. The follow were the agency's failures to protect the individual's funds, property and adhere to the financial policy:
· A detailed record of expenditures, purchases, and total balance left from the special purchase request money, was not kept daily for either occasion. The total balance was never documented.
· The last purchase made with special purchase money from February 2022, was made on 2/23/22. The remaining $16.56 from the balance of the funds, was not returned to the individual's representative payee-managed bank account until 4/19/22. The home does not have record of who had possession of the excess individual's funds from 2/23/22 until 4/19/22.
· $500 was received by the home on 5/24/22 and the last purchase wasn't made until 8/4/22, not within two weeks of receipt of funds.
· The $500 special purchase request was made to buy the individual "clothes, shoes, etc." The home does not have record of when the individual received all items purchased with their $500 request money. The home made purchases on 6/10, 6/20, 7/27, and 8/4 in 2022. The individual's property record was updated in June 2022 and not again until December 2022. The home updated the property record in December 2022 but also recorded some of the items purchased with the $500 were missing and initiated an investigation.
· $3.12 remained from the $500 request money. The special purchase request form is blank in the location to indicate when the money was returned to the individual or representative payee, and the amount of money returned. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | The Medication Administration Policy (Attachment 4) has been discussed with the Program Managers, Program Specialists, and Operation Directors by Quality Assurance on February 21, 2023. The policy directly details the documentation needed if the system is unavailable. This includes notification, paper documentation, updating the eMAR when available, and filing the paperwork. The policy is available to all Valley Community Services employees via the VCS Hub (intranet). The policy, outline, and attendance record have been submitted for review. Staff were trained on the changes to the policy on 2/21/23.
The Safeguarding Funds Policy (Attachment 5) has been updated and reviewed with the Program Managers, Program Specialists, and Operations Directors by Representative Payee on February 22, 2023. The policy includes documentation of purchases, remaining funds and submission to SharePoint. The policy is available to all Valley Community Services employees via the VCS Hub (intranet). The policy, outline and attendance record have been submitted for review.
Items purchased prior to special occasions, such as birthdays and Christmas will be added to the inventory list immediately upon acquisition. A note will be added regarding the holiday. Regulation 6400.43(b)(3) was retrained by the Central Region Operations Director on February 23, 2023, with the Program Managers. The outline and attendance record have been submitted for review. |
02/23/2023
| Implemented |
| 6400.68(c) | The home had a safe coliform well water test completed on 4/12/22 and not again until 9/27/22. The home's well water test completed on 7/5/22 indicated the sample exceeded the coliform standard of safe coliform levels and the water was not considered bacteriologically drinkable. The home did not produce records that the well water was tested safe again until 9/27/22 and the measures taken to prevent anyone in the home from drinking the well water from 7/5/22 until 9/27/22. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | All homes with well water are required to be tested at least every 3 months. The results of the testing are submitted to the Quality Assurance Department upon receipt. If/when results are above approved level, the Program Manager or designee will be informed immediately, and the home will begin using bottled water. The Facilities Director will contact the appropriate company to return and chlorinate/treat the well for continued use. Once the test is within normal limits, the home may stop using the bottled water. Documentation of all well checks, including retesting, is uploaded to SharePoint. The Program Managers were trained on regulation 6400.68(c) on February 23, 2023, by the Central Region Operations Director. The outline and attendance record have been submitted for review. |
02/23/2023
| Implemented |
| 6400.113(a) | Individual #1 moved into the home in May 2022. They did not receive fire safety training specific to their home until 10/4/22. | 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. | Individuals #1 was trained on their fire safety on 10/04/2022. Individual #1 moved to the current CLA in May 2022 and a Fire Drill was conducted on the move in date, however, the fire safety was not completed at that time, per regulation 6400.113(a). Program Managers and Program Specialists were trained on this regulation by the Central Region Operations Director on February 23, 2023. Outline and attendance record has been submitted for review.
To ensure no further infractions occur, all individuals transferred to an alternate CLA will complete a current Fire Safety Training and will be placed on SharePoint. The Quality Assurance Department will send an email to the Program Manager and Program Specialist on or before the transfer date. Once completed, the Program Manager will be responsible for scanning and the submission of the new fire safety training form. |
02/23/2023
| Implemented |
| 6400.142(f) | Individual #1's 5/2/22 dental hygiene plan was not updated to include dental hygiene orders from their dentist on 10/26/22. On 10/26/22 the individual's dentist stated the individual needs to complete warm saltwater rinses 2-3 times per day using 8 ounces of warm water and 1 teaspoon of salt for each mixture. The individual's 5/2/22 written dental hygiene plan states staff are to assist the individual (verbally and physically) to rinse with mouthwash daily, brush dentures daily, and check for thoroughness. The agency produced tracking records that individual #1 is to "perform a warm saltwater rinse 3 times a day with 8 ounces and one tablespoon of salt." This does not match the dentist's orders nor was it included in a plan or tracking on any other portion of the individual's dental hygiene plan. | 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. | Individual #1's Dental Hygiene plan has been updated with accurate information from the 10/26/22 appointment. Attachment 6 The Program Specialists have been retrained on regulation 6400.142(f), ensuring the plan is updated when changes are made at dental appointments. Dental Hygiene plans will continue to be reviewed annually and updated as necessary. Retraining on regulation 6400.142(f) was completed by the Central Region Operations Director on February 23, 2023. The outline and attendance record were submitted for review. |
02/23/2023
| Implemented |
| 6400.143(a) | Per the agency and Individual #1's dentist records, Individual #1 has dentures but refuses to wear them. The individual's refusals and the continued attempts to training the individual in the need to wear dentures was not documented in the individual's record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1 has a refusal plan for their dentures and staff have been trained. Attachment 7 Program Specialists were trained on 02/23/2023 by the Central Region Operations Director. Outline and attendance record were submitted for review. All Program Specialists will review their current plans and ensure that a refusal plan is not needed at this time. If dental hygiene plans require a refusal plan, the Program Specialist will create and train the plan prior to 03/01/2023. |
03/01/2023
| Implemented |
| 6400.144 | REPEAT from 1/24/22 annual inspection and 4/27/22 unannounced inspection:
On 5/19/22 the home documented a phone consultation to Individual #1's physician for the individual's cold-like symptoms. The phone consultation indicated that the physician wanted Individual #1 to take a Covid test and call back. There are no records that the home contacted the physician back after the individual took a Covid test on 5/19/22.
On 2/2/22 the individual's physician indicated glucose and cholesterol laboratory blood work was ordered for Individual #1. There are no records of the results of the tests, if the individual completed both ordered tests, or if there was any follow up determined based on the test results. | 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.
| All bloodwork and/or follow ups will be documented for proof that the prescriber for the individual was arranged and provided. Program Managers and Program Specialists were retrained on 6400.144 by the Central Region Operations Director on February 23, 2023. An outline and attendance record were submitted for review. When requesting a call back for outside testing, a medical review form will be completed on the date of the notification. It will include the exact information given to the prescriber. Although many prescribers have bloodwork results sent directly to their office, Program Managers and Program Specialists must request a copy from the blood draw agency. When received, the results should be attached to the medical review form requiring the testing. If unable to retrieve this information, a new medical review form will be completed stating that the prescriber was contacted and ensured results were obtained. |
02/23/2023
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's current, 11/6/22 assessment does not include their ability to complete dental hygiene. Their assessment states they are independent with dental hygiene, but also states the individual needs prompts to complete dental hygiene. The agency has created a dental hygiene plan for the individual that states staff must verbally and occasionally physically assist the individual in different areas of dental, gum, and denture daily hygiene. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Individual #1's dental hygiene plan Attachment 6 was reviewed, and an addendum was added to the current assessment. Attachment 8 This was also distributed to their team. The Program Specialists were trained by the Central Region Operations Director on February 23, 2023, on regulations 6400.181(e)(3)(iv). The outline and attendance record were submitted for review. |
02/23/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's current, 11/6/22 assessment does not state that the individual is edentulous and has dentures. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Individual #1's had an addendum added to the current assessment stating that Individual #1 is edentulous and has dentures. Attachment 9. This was also distributed to the team. The Program Specialists were trained by the Central Region Operations Director on February 23, 2023, on regulations 6400.181(e)(3)(iv). The outline and attendance record were submitted for review. |
02/23/2023
| Implemented |
| 6400.211(b)(3) | The name, address, and telephone number of the person able to give consent for emergency medical treatment is not located in Individual #1's record. The individual's face sheet states their supports coordinator is their legal guardian. However, according to Valley Community Services, Individual #1 does not have a legal guardian. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Individual #1 has no family to contact for emergency medical treatment. The pertinent information sheet has been revised to state that there is no next of kin. The agency will contact the Supports Coordinator if end of life decisions needs to be made. The team will convene to discuss options.
The Program Managers have been retrained on regulations 6400.211(b)(3) by the Central Region Operations Director on February 23, 2023. Each individual with no next of kin will have the Supports Coordinator removed from this area on the pertinent information sheet. An outline and attendance sheet have been submitted for review. |
03/15/2023
| Implemented |
| 6400.216(a) | Identifying information for Individual #2 and their medical supplies worn, was unlocked and accessible to all. Many boxes of the individual's adult briefs were stored on the sun porch of the home. The boxes contained the individual's name, address, and could identify the medical supplies in the boxes. | An individual's records shall be kept locked when unattended.
| To ensure all individual records are kept locked when unattended, all boxes of medical supplies for Individual #2 were placed into bins with closing lids. Program Managers were retrained on 6400.216(a) by the Central Region Operations Director on February 23, 2023. An outline and attendance record were submitted for review. |
02/23/2023
| Implemented |
| 6400.32(t) | Individual #1's individual plan states most food in the home is locked in the staff office, there is a refrigerator and freezer that is locked and a cabinet for dried goods that is locked. The home does not have any restrictive plans in place approved by a human rights committee. During the inspection, Individual #1's food items and drinks were locked and inaccessible in the staff office. Items locked in the staff office were drink mixes, two cases of soda, 7 packs of Oreo's, a pack of wafers, Nutter Butters, and a few other snack items.
Individual #1 makes large purchases with their food stamp card, has spent hundreds of dollars in October and December 2022 at Sam's Club per the house manager and director of quality assurance. Bulk purchases or bulk items of food for Individual #1 could not be located at the home during the inspection. | An individual has the right to access food at any time. | Individual #1's food and drink items are no longer locked. Attachment 10. The Program Specialist has submitted an ISP correction form to the Supports Coordinator to remove the statement. All Program Specialists were trained by the Central Region Operations Director regarding regulation 6400.32(t) on February 23, 2023. No items are to be locked unless there is a specific restriction for the individual. Outline and attendance record has been submitted for review. |
02/23/2023
| Implemented |
| 6400.46(a) | Staff person #3 only received fire safety training at the agency's day program in 2021 and 2022. They did not receive fire safety training specific to any of the agency's residential homes the staff works at or oversees. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Valley Community Services has updated the Preservice Orientation Attachment 11 and Transfer Orientation documents to include individual specific trainings. The changes to the documents were trained on 2/9/23, 2/15/23, and 2/16/23 by the Director of Human Resources. The outline and attendance record have been submitted for review. |
02/16/2023
| Implemented |
| 6400.51(b)(5) | REPEAT from 4/27/22 unannounced inspection: Staff person #1 did not receive orientation training on the specific individuals plans, protocols, and all health and safety needs prior to working with individuals. Their training record does not include any records of these trainings. | The orientation must encompass the following areas: Job-related knowledge and skills. | Valley Community Services has updated the Preservice Orientation Attachment 11 and Transfer Orientation documents to include individual specific trainings. The changes to the documents were trained on 2/9/23, 2/15/23, and 2/16/23 by the Director of Human Resources. The outline and attendance record have been submitted for review. |
02/16/2023
| Implemented |
| 6400.52(c)(1) | The agency does not have records that Staff person #4 received annual training in the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #4 will receive training on Person-Centered Practices, Community Integration, Individual Choice, and Supporting Individuals to develop and maintain relationships on 3/15/23. Valley Community Services ensures all staff are trained on the core subjects stated in the 6100 regulations and within regulation 6400.52(c)(1). Each November the Human Resources and Quality Assurance department meet to determine what training would be acceptable and appropriate for each of the subjects. The training is assigned to current staff with a date completed by 3/31. Starting each April, the Human Resource Specialists send reminders to the staff and their assigned Program Manager if not completed. New staff are assigned the training upon hire and are required to complete all prior to working with the individuals alone. Outline and attendance sheet have been submitted for review. |
03/31/2023
| Implemented |
| 6400.165(c) | REPEAT from 4/27/22 unannounced inspection: Individual #1 is prescribed Senna-s tablet to be administered at bedtime if no bowel movement in 3 days. Individual #1 had a bowel movement on 4/26/22 and not again until 4/30/22. Senna-s mediation was never administered. | A prescription medication shall be administered as prescribed. | Program Managers have been retrained on 6400.165(c) by the Central Region Operations Director on February 23, 2023. Program Managers and supervisory staff are required to review Therap documentation regarding intake and elimination daily. A T-log is to be created for all staff working at the home stating the date and time the individual would have gone 72 hours without a bowel movement. All medication administrators have been trained to contact the on-call system to verify the order for Senna-s is needed that evening. An outline and attendance form has been submitted for review. |
02/23/2023
| Implemented |
| 6400.166(a)(2) | Individual #1's January 2022 to April 2022 medication administration records (mars) list all daily medications prescribed by one physician. The individual's May 2022 to June 2022, and August 2022 to October 2022 mars list their daily and as needed medications being prescribed by a different physician (only one). Individual #1's July 2022 list a different prescribing physician for their daily medications. However, according to the medication labels on each daily medication, they are prescribed by various physicians and each corresponding monthly mar did not reflect the prescribing physician for each medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Prior to the rollout of the eMar system, our current pharmacy listed only one physician on prepopulated paper Mars. Program Manager or designee is responsible to ensure the information for each medication is accurate, including prescribing physician. With the implementation of the eMAR, the system automatically adds the prescribing physician for each individual medication. It is listed after the medication name and strength. Program Managers were retained on regulation 6400.166(a)(2) on February 21, 2023, by the Quality Assurance department. As medications are being checked in through pharmacy waiting, it is the Program Manager or designee responsibility to ensure that the correct prescribing physician is assigned to the correct medication. An outline and attendance record have been sent for review. |
02/21/2023
| Implemented |
| 6400.166(a)(9) | Individual #1's December 2022 and January 2023 electronic medication administration records (mars) do not include a record of their prescribed as-needed medications. The individual's mars did not include any regulatory information required under Chapter 6400.166(a)(1)-(16). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | PRN/OTC medications are given when symptoms match the physicians PRN orders. The eMAR system began on 12/01/2022. The current approved PRNs/OTCs are listed in separate areas for review. One is the order that the physician signed and is kept in the chart. This form is updated at least annually. The second is a report within the eMAR system. It is the PRN/OTC Sheet report. Only approved PRNs are listed with their use and when to contact the physician if the symptom is not alleviated.
The Medication Administration Policy addresses the steps to print out a hard copy of the medication. This can be completed by any person who is a current medication administrator. Training on this process was completed on February 21, 2023, and included where the policy is located within the agency's intranet. The outline and attendance record have been submitted for review. |
02/21/2023
| Implemented |
| 6400.166(a)(12) | Staff initialed as administering Apap medication three time to Individual #1 on 5/19/22. The time of administration was not recorded for the 3rd administration on 5/19/22.
Staff initialed as administering Aller-chlor mediation to Individual #1 twice on 5/20/22. The time of administration was not recorded for one of the administrations.
Staff initialed as administering Apap to Individual #1 3 times on 5/20/22. The time of administration was not recorded for two of the administrations. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Valley Community Services began utilizing an eMAR as of 12/01/2022. All medication administrators are instructed to include their signatures, initials, date, time, medication, and effectiveness for all PRN medications. The eMAR system places the initials, signature, the date and exact time of administration, as the med passer completes the pass of the PRN. The system also prompts the home to address if the medication was effective or ineffective. These instructions are on the VCS Hub (intranet) as a Tip Sheet. The Program Managers have been retrained on February 21, 2023, by the Quality Assurance Associate. Program managers or designee are required to review CaraSolva daily to ensure all information is accurate and provided when PRNs are administered. The outline and attendance record have been submitted for review. |
02/21/2023
| Implemented |
| 6400.186 | Individual #1's individual plan includes a plan to address any social, emotional, or environmental needs as staff witness them. The plan states staff are to document any triggers they observe. The house manager and the director of quality assurance discussed with the Department how over the past year, Individual #1 was found "hiding" in their bedroom, bathroom, and in their bedroom closet on a few occasions. The home did not provide any tracking or records related to any emotional or behavioral concerns they witnessed over the year or how they assisted the individual through those instances.
Individual #1's individual support plan and assessment state they are working on a money identification goal to differentiate between coins and bills. There are no records this is being completed. | The home shall implement the individual plan, including revisions. | Individual #1's staff were retrained on documentation for triggers they observe, especially regarding the need to conceal their whereabouts. The staff will be tracking all incidents in Therap under "New Behaviors". Training and attendance sheet have been submitted for review. The Program Specialist will receive a monthly report from the Behavior Specialist.
The Program Specialist sent an ISP Correction to remove the Money Identification goal and added household chores four times a week. Attachment 12. |
02/23/2023
| Implemented |
| 6400.213(1)(i) | The following violation is reference to Pa Code 55 Chapter 6400.213(1)(ii), content of records, each individual's record must include the following information: personal information, including: race. The Certified Licensing System (CLS) does not currently have an electronic option to include the verbiage under 6400.213(1)(ii).
Individual #1's record does not clarify their race. The individual's face sheet containing pertinent information states the individual is white. However, their individual plan in their record states there are Asian, non-Hispanic. There are no records clarifying or correcting either document. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #1's Program Specialist has submitted an ISP correction form to the Supports Coordinator to adjust the race to White. Attachment 13 Program Specialists were retrained on 6400.213(1)(i) by the Central Region Operations Director on February 23, 2023 on the requirement to review all information on ISPs when they become available, including but not limited to the information found on the Pertinent Information Sheet. An outline and attendance sheet has been submitted for review. |
02/23/2023
| Implemented |
| Article X.1007 | Valley Community Services, is required to maintain 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 person #1 was hired on 9/13/22 and reported to the agency on 8/29/22 they resided outside the state of Pennsylvania in the last two years. The agency did not produce records with results of a completed Federal Bureau of Investigation (FBI) criminal history record check for Staff person #1. | 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. | Valley Community Services will send prospective employees for fingerprinting following the completion of the onboarding documents. Upon completion of the Pennsylvania Residency document, the Human Resources Recruiter will review the form to determine if the prospective employee resides within the Commonwealth of Pennsylvania. If the prospective employee resides outside the Commonwealth of Pennsylvania within the past 2 years, the Recruiter will submit an application for an FBI criminal history record in addition to the Pennsylvania criminal history record check.
The Prospective employee will also need to complete the FBI clearance and will provide the Human Resource Recruiter with the receipt that the fingerprinting was completed. The prospective employee will be required to submit the fingerprinting to the Human Resource Recruiter upon their first day of employment. The Human Resource Recruiter was trained on 2/14/2023 by the Director of Human Resources. The outline and attendance record have been submitted for review. |
02/14/2023
| Implemented |