| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(a) | There was no documentation for staff #1 having training on the daily operation of the facility. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | Training has been completed. See appendix L |
12/02/2017
| Implemented |
| 2380.36(d) | Staff #1 & #2 did not have training on program planning or implementation. | Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | Training has been completed. See appendices L and CC |
12/02/2017
| Implemented |
| 2380.53(a) | Room #8 had Individuals that were not aware of poisonous materials and there was a large cabinet in the room which was found unlocked and contained: 8-10 large bottles of antibacterial hand sanitizer, 9 cans of Lysol, 8-10 containers of antiseptic wipes and antiseptic spray. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The cabinet is now locked (see Appendix AA) and the administrative assistant will complete a walk through of the rooms daily to ensure all items are locked that are necessary using a checklist form (see Appendix J) |
12/02/2017
| Implemented |
| 2380.55(a) | The bathroom by room #8 was very dirty, the curtain used as a privacy screen for the one toilet was very dirty with stains. The medication box in Room #8 contained contaminated medications cups and spoons. The medication cups where not in a protective container, they were loose on the bottom of the medication box which appeared to be dirty. | Clean and sanitary conditions shall be maintained in the facility. | All items have been corrected. See Appendices X4 and Z |
12/02/2017
| Implemented |
| 2380.58(a) | There was broken tiles inside the exit door in room #8. | Floors, walls, ceilings and other surfaces shall be in good repair. | A work order has been submitted for tile to be repaired. See Appendix Y |
12/02/2017
| Implemented |
| 2380.69(f) | Individuals in Room #8 uses a bathroom that does not lock and 1 toilet is exposed with no privacy. There is a door that is used as an exit that is not covered. | Privacy shall be provided for all toilets by partitions, doors or curtains. | All items have been correct. See Appendices X, X2 and X3. |
12/02/2017
| Implemented |
| 2380.82 | Room #8's exit was blocked with a wooden chair. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | This has been corrected. See appendix W |
12/02/2017
| Implemented |
| 2380.84 | The Main House building was inspected by a fire safety expert onsite from March 9-10, 2016 and not again until April 3-7, 2017. The agency did not keep documentation of the exact date that The Main House building location received the inspection. The fire safety expert only indicated in a letter that they inspected 6 buildings from April 3-7, 2017. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | See appendix K
A new Qware preventative maintenance system has been implemented to schedule fire safety inspections to ensure no further lapse. |
12/02/2017
| Implemented |
| 2380.89(b) | The fire drill held 10/12/17 utilized additional staff not included in the staffing pattern | Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average. | See Appendix V
An email from the surveyor indicated this citation should not be included as all staff assisting with the drill work in the building daily. |
12/02/2017
| Implemented |
| 2380.111(a) | Individual #1 had a physical exam completed on 8/2/16 and not again until 8/25/17, outside of the annual time frame. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | See Appendix R - Nurse training |
12/31/2017
| Implemented |
| 2380.111(c)(5) | Individual #1 had a Tuberculin skin test with negative results completed on 4/20/15 and not again until 5/25/17, outside of the annual time frame. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | see appendix R - Nurse Training |
12/31/2017
| Implemented |
| 2380.111(c)(6) | Individual #1's 8/25/17 physical exam form indicated that he/she was not free of communicable diseases and did not indicate specific precautions that should be taken to prevent the spread of the disease(s) to other individuals. His/Her 2016 physical exam form did not indicate if he/she was free of communicable diseases, the field was left blank. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | see appendix R - Nurse Training |
12/02/2017
| Implemented |
| 2380.111(c)(7) | REPEAT from 9/26/16 annual inspection: Individual #2's 6/9/17 physical examination form did not indicate health maintenance needs including the need for blood work at recommended intervals. The field only indicated labs already done in April.' | 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. | see appendix R - Nurse Training |
12/02/2017
| Implemented |
| 2380.111(c)(8) | REPEAT from 9/26/16 annual inspection: Individual #1's 8/25/17 physical examination form indicated that he/she did not have any physical limitations and that he/she could perform all activities as tolerated. However he/she is in a wheelchair at all times and requires the adaptive equipment of a stander on occasion. This was not indicated a physical limitation for activities. Individual #2's 6/9/17 physical examination form indicated that he/she is scooter bound can do no physical activity' however he/she is able to move/utilize his/her arms, hands, and head for exercise. Individual #2 is also wheelchair bound, not scooter bound. | The physical examination shall include: Physical limitations of the individual. | see appendix R - Nurse Training |
12/02/2017
| Implemented |
| 2380.111(c)(9) | Individual #2's 6/9/17 did not include his/her allergies to sulfa drugs and band aid adhesive; the section was blank. | The physical examination shall include: Allergies or contraindicated medication. | see appendix R - Nurse Training |
12/02/2017
| Implemented |
| 2380.111(c)(10) | REPEAT from 9/26/16 annual inspection: Individual #1's 8/25/17 physical examination form did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. Individual #2's 6/9/17 physical exam indicated none' for medical information pertinent to diagnosis and treatment in case of an emergency. However Individual #2 has grand mal seizures, is wheelchair bound, and diagnosed with cerebral palsy that is pertinent medical information to know when administering treatment. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | see appendix R - Nurse Training |
12/02/2017
| Implemented |
| 2380.124(b) | Individual #1's medication log was not initially immediately after administering Risperdone 2mg, 1 tablet at 2pm on 9/21/17, 9/6/17, and 1/16/17. Staff initialed the medication record the following day to indicate that Riperidone was actually administered as ordered the previous day. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | The target staff member will be retrained on documentation procedures no later than 12/31/2017, and the appropriate corrective feedback will be delivered |
12/31/2017
| Implemented |
| 2380.173(9) | Individual #1's identification sheet in his/her record indicated that he/she was to follow a regular diet. However his/her 8/25/17 physical examination form indicated that he/she was to follow a GERD, low acid/low spice diet. His/Her Individual Support Plan (ISP) indicated that he/she was to follow a regular diet but food needs to be cut into small pieces for him/her and he/she may need to be fed certain foods. Due to GERD diagnosis, he/she avoids sauces, fried foods, caffeine and chocolate. Avoid fatty and fried foods, milk, chocolate, spearmint, peppermint, caffeine, citrus fruits and juices, tomato products, sauces, and pepper seasoning. His/Her food needs cut into very small pieces.' His/Her 10/11/17 assessment indicated that he/she required food to be cut up into bite sized pieces and follow a regular diet with GERD precautions.' His/Her assessment also indicates that he/she is to eat at a 90 degree angle and needs close supervision when eating as he/she may steal/grab food from others. He/She may have episodes of coughing or choking during or after meals.' | Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | See Appendices C, D, E and F.
The identification has been updated to include the proper dietary recommendations, following an observation form the director of healthcare, as well a conversation with the family of the individual. |
12/02/2017
| Implemented |
| 2380.176(a) | All Individuals records were found unlocked in a filing cabinet in the restroom by room #8. Individual records in the following rooms where found unlocked- #1, 2, 3, 4. In room #6 there was found hanging on the wall an Individuals reposing chart with a photo of the Individual. | Individual records shall be kept locked when they are unattended. | See Appendices O, P, Q, S, T and U.
All items have been corrected. Daily checks for unlocked supplies will be completed the administrative assistant. |
12/31/2017
| Implemented |
| 2380.181(a) | Individual #1's assessment was completed on 7/6/16 and not again until 10/11/17, outside of the annual time frame. Individual #2's assessment was completed on 1/11/16 and not again until 1/31/17. Individual #4's 2017 assessment was not completed. The program specialist for Individual #4 printed out Individual #4's 7/15/16 assessment and re-dated it for completion on 3/8/17. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individual #1, 2 and 4 will have assessments re done by 12/31/2017,
A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/31/2017
| Implemented |
| 2380.181(e)(3)(ii) | Individual #1's 10/11/17 assessment did not indicate that he/she uses his/her iPad and Go Talk application for communication needs at program. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Communication. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A)
Individual #1 will have an updated assessment to include communication using the updated assessment template (appendix B) by 12/31/2017 |
12/31/2017
| Implemented |
| 2380.181(e)(13)(ii) | - Individual #1's 10/11/17 assessment did not include his/her progress and current level in motor and communication skills. The 2017 assessment was the same as 2016 assessment. His/Her Individual Support Plan (ISP) indicated that over the last year physical therapy at Melmark was discontinued due to him/her being unresponsive while getting physical therapy. Individual #2's 1/31/17 assessment did not include his/her progress in communication skills. His/Her 2017 assessment was the same as his/her 2016 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Individual #1 and 2 will have new assessments completed to include the missing items by 12/31/2017 using the updated assessment template (appendix B) |
12/31/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's 10/11/17 assessment did not include his/her progress and current level in socialization skills. The 2017 assessment was the same as 2016 assessment. Individual #2's 1/31/17 assessment did not include his/her progress in socialization skills. His/Her 2017 assessment was the same as his/her 2016 assessment. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A)
A new assessment will be completed by 12/31/2017 using the updated assessment template (appendix B) |
12/31/2017
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's 10/11/17 assessment did not include his/her progress and current level in recreation skills. The 2017 assessment was the same as 2016 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A)
A new assessment will be completed using the updated assessment template (appendix B) |
12/31/2017
| Implemented |
| 2380.181(e)(14) | Individual #1's 10/11/17 assessment and Individual #3's 10/11/17 assessment did not include their ability to swim. Individual #1 is wheelchair bound and his/her assessment only indicated that he/she required supervision while he/she was in the pool with a flotation device. | The assessment must include the following information: The individual's knowledge of water safety and ability to swim. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A)
A new assessment will be completed by 12/31/2017 using the updated assessment template (appendix B) |
12/31/2017
| Implemented |
| 2380.181(f) | Individual #1's 10/11/17 assessment was completed late and sent to some team members on 10/11/17, therefor it was not sent to any team member prior to his/her annual Individual Support Plan (ISP) meeting on 8/14/17. His/Her assessment was not sent to his/her behavior support person. Individual #2's 1/31/17 assessment was not sent to his/her behavior support persons | 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). | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A) |
12/31/2017
| Implemented |
| 2380.183(3) | Individual #1's Individual Support Plan (ISP) did not include the method of evaluation for his/her active day' outcome. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
An email was sent to the supports coordinator to add the method for evaluation for the outcomes. See appendix I. |
12/31/2017
| Implemented |
| 2380.183(4) | - Individual #1's Individual Support Plan (ISP) did not include his/her level of supervision. Individual #1 required 1:1 supervision level and their ISP indicated he/she required 1:1 and he/she was always supervised.' The ISP did not indicate if visual, arm's length, or hearing distance was the requirement for 1:1 staff. Individual #2's ISP did not include that he/she required visual supervision at all times at the day program and in the community. | 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. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
See Appendices I and M for emails sent to the SC requesting the appropriate visual level of supervision be added to the ISP. |
12/31/2017
| Implemented |
| 2380.183(5) | Individual #4's Individual Support Plan (ISP) did not include a protocol to address his/her social, emotional, and environmental needs at the Main House program. His/Her ISP indicated that he/she had a protocol for the day program Marcus. | 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. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Individual's Plan of Support has been updated. See Appendix N.
An email was sent to the SC to update the location of the day program in the ISP for the Plan of Support to Main House. See Appendix H |
12/31/2017
| Implemented |
| 2380.183(7)(i) | Individual #1's and #4's Individual Support Plans (ISP) did not include his/her potential to advance in vocational programming. | 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: Vocational programming. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Emails were sent to respective SC's to add potential to advance in the ISP. See Appendices I and H |
12/31/2017
| Implemented |
| 2380.183(7)(iii) | Individual #1's, #2's, and #4's Individual Support Plans (ISP) did not include his/her potential 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. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Emails were sent to respective SC's to add potential to advance in the ISP. See Appendices I, M and H |
12/31/2017
| Implemented |
| 2380.184(a)(1)(iii) | Individual #1's, #2's, and #4's annual Individual Support Plan (ISP) meeting did not include a direct service worker from the day program provider. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 2380.186 (relating to ISP review and revision).A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering a service to the individual. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/31/2017
| Implemented |
| 2380.185(b) | - Individual #1's Individual Support Plan (ISP) indicated that he/she needed to be monitored during meal times to make sure he/she did not pocket food, did not take bites that were too big, did not take drinks that were too big, did not grab other items around him/her and put in his/her mouth, was eating a 90 degree angle so he/she did not choke and was provided with very small bites. During the inspection, Individual #1 was given popcorn while his/her 1:1 staff was moving around the room preparing other food items for other individuals, not watching Individual #1 eat or drink. Individual #1 was hunched over and not eating at a 90 degree angle. There were multiple pop corn kernels sitting on his/her protective clothing covering within arm's reach and accessible to him/her to put in his/her mouth.
· Individual #2's ISP indicated that he/she required to be repositioned a few times throughout the day and to use a round pillow. There was not documentation to indicate that this occurred.
· Individual #4's ISP indicated he/she was working on an outcome to listen to music. This is not the current outcome he/she is working on. | The ISP shall be implemented as written. | Appendix C (Director of Healthcare's feeding observation) - Individual #1
Appendix D (updated protocol and staff training) Individual # 1
Appendix E (email regarding conversation with family) Individual #1
Appendix F (email regarding popcorn as snack being discontinued )
Appendix G - re-positioning chart has been implemented for individual #2
Appendix H - email sent to individual #4 SC to include appropriate outcome in ISP
Individual #1 will have his assessment re-done by by 12/31/2017. and his protocol has been updated to reflect the proper eating precautions. |
12/31/2017
| Implemented |
| 2380.185(b) | Individual #1 has a plan for eating and what his/her 1:1 staff are to be doing. It was observed that Individual #1's 1:1 staff was not following the plan as specified in the ISP. Individual #1 is to be watched while eating and the 1:1 was helping other Individuals during snack time and Individual #1 was observed choking/coughing while eating. | The ISP shall be implemented as written. | Appendix C (Director of Healthcare's feeding observation) after two observations, the Director of Healthcare did not note any concerns with feeding for individual #1 and did not recommend that swallow study be pursued at this time.
Appendix D (updated protocol and staff training) Individual #1's 1:1 staff was retrained on feeding precautions.
Appendix E (email regarding conversation with family)
Appendix F (email regarding discontinuing popcorn as snack) |
12/31/2017
| Implemented |
| 2380.186(a) | Individual #2 had an Individual Support Plan (ISP) review completed late on 4/12/17. The 4/12/17 review reviewed data from 12/28/16-3/27/17, making the completion of the review on 4/12/17 sixteen days late. Individual #2 then did not have another ISP review completed until 7/26/17. The 7/26/17 review reviewed data from 3/28/17-6/27/17; being completed outside the 90 day review time frame. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/31/2017
| Implemented |
| 2380.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews did not review his/her behaviors, behavior support plan, 1:1 supervision. Individual #2's ISP reviews did not review his/her behaviors, behavior support plan, seizures, repositioning, physical therapy provided at day program, or community participation. Individual #4's ISP reviews did not review his/her SEEN plan. The review of the SEEN plans for the past year were not completed until 10/12/17. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/31/2017
| Implemented |
| 2380.186(d) | The Individual Support Plan (ISP) reviews for Individual #1 were not sent to his/her behavior specialist. Individual #2's ISP reviews were not sent to both his/her behavior support persons. Individual #4's ISP review completed on 10/18/16 was sent to the team on 10/3/16, prior to completion. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Individual #1 and #2 will have their ISP reviews sent to their behavior support specialist by 12/31/2017 |
12/31/2017
| Implemented |
| 2380.186(e) | The option to decline Individual #1's and #2's Individual Support Plan (ISP) reviews were not offered to either of their behavior support persons. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/31/2017
| Implemented |