| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(b)(2) | The program spcialist was not trained in her responsibilites and job description yet. He/She has been acting as the program specialist since the program opened on 4/23/15. (This violation covers all of 33(b) regulation) | The program specialist shall be responsible for the following: Providing the assessment as required under § 2380.181(f) (relating to assessment). | Program Specialist has reviewed and signed the job description which has been placed in the personnel file (Appendix A). |
07/26/2016
| Implemented |
| 2380.36(h) | The program specialist confirmed that training content for Staff #2's and #3's trainings was not kept. Examples of staff training that did not have content was Fire Saftey Review, Medical Issues for people with Severe Disabilities, First aid/CPR, Goal Planning for individuals, Farm Orientation, and Autism Spectrum training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Training content (i.e. copy of powerpoint or agenda) will be included in the training files (Appendix B). |
07/26/2016
| Implemented |
| 2380.53(a) | Two bottles of Rubbing Alcohol were found in an unlocked and accessible cabinet in the large program room. Two bottles of Germ-X were found unlocked and accessible near the kitchen sink and staff office in the smaller program building. Both of these substances contained labels which read: "contact poison control center if ingested." Individuals #1-#4 were not safe around poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Staff were trained on 6/28/16. They were instructed that all substances containing labels that read ¿contact poison control center if ingested¿ must be locked (Appendix C). Rubbing alcohol and germ x were put in locked closet. |
07/26/2016
| Implemented |
| 2380.53(b) | An unmarked, clear spray bottle was found on a hutch in the kitchen program area. The bottle had "soap H2O" written on it with permanent marker. Staff #1 confirmed it was dishwashing soap mixed with water. | Poisonous materials shall be stored in their original, labeled containers. | Staff were trained on 6/28/16. They were instructed that unlabeled bottles with dish soap and water are not allowed (Appendix C). They were removed. |
07/26/2016
| Implemented |
| 2380.55(e) | There was a trashcan about 3 feet high on the back porch of the main program area that did not have a lid to prevent the penetration of insects and rodents. | Trash outside the facility shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Trash can without lid was replaced with a trash can with a lid (Appendix D). |
07/26/2016
| Implemented |
| 2380.65 | The steps on the back porch of the main program area were not equipted with non-skid surfaces. | Interior stairs and outside steps shall have a nonskid surface. | Non skid strips added to steps (Appendix E). |
07/26/2016
| Implemented |
| 2380.72(a) | The outside walkway leading from the main program area to the back porch of the program area, contained two ceramic flower pots in the middle of the walkway. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Flower pots removed from walkway (Appendix F). |
07/26/2016
| Implemented |
| 2380.87(b) | Strobe lights were not present in the restrooms at the facility. Individual #4 is hearing impaired. | 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. | Individual #4 has cochlear implants and is able to hear a fire alarm. However, he has the mental age of less than a one year old and cannot be taught to exit a building during a fire even with strobe lights. Additionally, anytime he is in the bathroom, he is assisted by a 1:1 staff who pulls down his pants and diaper, wipes him, pulls up his pants, flushes, and washes his hands. The 1:1 staff would assist him to exit the bathroom and to safety in the event of a fire. The addition of a strobe light would do nothing to increase his safety. |
07/26/2016
| Implemented |
| 2380.89(c) | The fire drill record did not include which exit was used and whether the fire alarm was 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. | Fire drill documentation form was revised to include exits used and if the fire alarm was operative (Appendix G). |
07/26/2016
| Implemented |
| 2380.89(g) | The fire drill record did not include if the individuals evacuated to a designated meeting place outside of the building. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Fire drill documentation form was revised to include if each individual evacuated to a designated meeting place outside the building (Appendix G). |
07/26/2016
| Implemented |
| 2380.89(h) | The fire drill record did not indicate if a fire alarm was set off during each fire dirll. | A fire alarm shall be set off during each fire drill. | Fire drill documentation form was revised to include if a fire alarm was set off during each fire drill (Appendix G). |
07/26/2016
| Implemented |
| 2380.91(a) | Individual #2's date of admission to the facility was 9/8/15. They did not receive fire safety training until 9/15/15. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility. | Individual #2¿s scheduled date of admission was 9/8/15. However, she did not actually start attending Red Tomato Farm until 9/15/15, the date of her fire safety training (Appendix H). |
| Implemented |
| 2380.111(a) | Individual #2's date of admission to the facility was 9/8/15. At the time of licensing on 6/17/16, the facility still did not have a physical examination form completed for Individual #2. Staff #1 confirmed there was not a physical examination on file for Individual #2. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | There is a physical exam form for Individual #2 (Appendix I). |
07/26/2016
| Implemented |
| 2380.111(c)(1) | The physical examination form completed on 8/5/15 for Individual #1 did not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | There is a medical history for individual #1 (Appendix J). |
07/26/2016
| Implemented |
| 2380.111(c)(8) | The physical examination form completed on 12/14/15 for Individual #3 did not include physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | A letter was sent to Individual #3¿s group home requesting documentation of her physical limitations (Appendix K).physical limitations |
07/26/2016
| Implemented |
| 2380.113(a) | Staff #3's date of hire was 2/16/16 and they did not have a physical exam completed until 4/22/16. | 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. | New employees will not begin work until the physical and TB forms are completed. |
07/26/2016
| Implemented |
| 2380.128(a) | Staff #1 did not complete the Department's Medications Administration Course and was administering medications from May-September 2015. Staff #2 had medication administration training completed on 3/20/14 and not again since. He/She has been passing medications since his training expired on 3/20/15. | A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Staff #1 and #2 completed medication administration training under a previous location (Hope Springs Farm in Hershey, PA, Dauphin County). When Hempfield Behavioral Health attempted to retrieve it¿s records including medication administration training records from this prior location, HBH was forced to contact the Pennsylvania State Police and it¿s attorney to recover records but this effort was not completely successful and medication administration training records were not recovered. HBH also attempted to recover these records from the trainer Angela Tancasas but she was unresponsive to these repeated requests. If these forms are available through licensing due to historic review of Hope Springs Farm, HBH requests a copy.
HBH searched for a medication administration trainer to update staff #2¿s training without success. This included contacting licensing for advice on this matter. Staff #1 became a certified trainer as soon as the Pennsylvania Department of Public Welfare made it available. Staff #2 completed medication administration trainer certification on 10/6/15 (Appendix L).
|
07/26/2016
| Implemented |
| 2380.173(1)(iv) | Individual #1's record did not include his religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Individual #1's religious affiliation is Christian and is documented in his file. |
07/26/2016
| Implemented |
| 2380.181(d) | The program specialist did not date the assessments for any indiividuals in the program. The dates were prepopulated and the system is not a secure system that only the program specialist could access. | The program specialist shall sign and date the assessment. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(4) | The assessment for Individual #2 completed on 11/2/15 indicated that they required 1:1 supervision but that they could also have 5 minutes alone time. The need for supervision was not able to be determined. | The assessment must include the following information: The individual¿s need for supervision. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(5) | The assessments for all Individuals did not include their ability to self-administer medications. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(6) | The assessments for all Individuals did not include their ability to safely use or avoid poisonous materials. | 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. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(7) | The assessment for Individual #3 completed on 7/8/15 did not include their knowledge of the danger of heat sources and their ability to sense and move away quickly from the heat source. The assessment indicated that Individual #2 was "not assessed" in this area. | 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. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(9) | The assessment for Individual #1 completed on 5/2/16 did not include their functional and medical limitations. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(10) | The assessments for all Individuals did not include their lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(13)(vi) | The assessment for Individual #3 completed on 7/8/15 did not include their progress over the last 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. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(e)(14) | The assessments for all Individuals did not include their knowledge of water safety and ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.181(f) | The assessment for Individual #1 completed on 5/2/16 was not sent to his/her residential provider. | 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). | Assessments were revised and re-sent to participant, group home provider and Supports Coordinator (Appendix M). |
07/26/2016
| Implemented |
| 2380.183(4) | The Individual Support Plan for Individual #1 did not include the protocol and schedule outlining specific periods of time for the individual to be without direct supervision. Individual #1's assessment indicated that they could be without direct supervision for up to 15 minues. | 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. | The Individual Service Plans are the responsibility of and are written by the Supports Coordinators of the individuals. Hempfield Behavioral Health has no control over what is included in them. HBH has sent letters to Supports Coordinators requesting this information be added to these individuals¿ ISPs (Appendix O) |
07/26/2016
| Implemented |
| 2380.183(5) | The Individual Support Plans (ISPs) for Individuals #1-#3 did not include a protocol to address the social, emotional and environmental needs of the individuals. Individual #1 was prescribed Seroquel for Mood Disorder. Individual #2 was precribed Seroquel for Dysthmyic Disorder/Reactive Depression. Individual #3 was prescribed Clonazepam, Risperdone, and Sertraline for Anxiety and Naltrexone for Impulsiveness. | 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. | The Individual Service Plans are the responsibility of and are written by the Supports Coordinators of the individuals. Hempfield Behavioral Health has no control over what is included in them. HBH has sent letters to Supports Coordinators requesting this information be added to these individuals¿ ISPs (Appendix O) |
07/26/2016
| Implemented |
| 2380.183(7)(iii) | The Individual Support Plan for Individual #3 did not include their protential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | The Individual Service Plans are the responsibility of and are written by the Supports Coordinators of the individuals. Hempfield Behavioral Health has no control over what is included in them. HBH has sent letters to Supports Coordinators requesting this information be added to these individuals¿ ISPs (Appendix O) |
07/26/2016
| Implemented |
| 2380.185(b) | The Individual Support Plan for Individual #1 indicated that all staff are trained in his/her ISP and behavior support plan before working with him. There was no record to show that staff were trained in either of these documents for Individual #1. | The ISP shall be implemented as written. | Staff received training on 7/19/16 on Individual #1¿s ISP and Behavior Plan for Red Tomato Farm (Appendix P). |
07/26/2016
| Implemented |
| 2380.186(b) | Individual #3 did not sign or date the Individual Support Plan (ISP) reviews completed for him/her on 10/22/15, 1/12/16, and 4/11/16. Individual #2 did not sign or date the ISP reviews completed for him/her on 2/4/16 and 5/9/16. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | HBH ISP review form revised to include participant signature (Appendix Q) |
07/26/2016
| Implemented |
| 2380.186(c)(2) | The Individual Support Plan (ISP) reviews completed for Individual #3 on 10/22/15, 1/12/16, and 4/11/16 did not include a review of her protocol to address his/her social, emotional and enviormental needs. The ISP reviews completed for Individual #2 on 2/4/16 and 5/9/16 did not review their 1:1 staffing ratio or their protocol to address his/her social, emotional and enviormental needs. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Revisions were made to include need for 1:1 assistance and protocol to address social, emotional and environmental needs (Appendix R). |
07/26/2016
| Implemented |
| 2380.186(e) | The program specialist did not notify the plan team members for Individuals #2 and #3 of the option to decline the Individual Support Plan (ISP) review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | HBH ISP review form revised to include the individual¿s right to decline the ISP Review Documentation (Appendix Q). |
07/26/2016
| Implemented |