| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | A large container of laundry detergent was by the washer and dryer in area 1. The container was not locked and accessible to individuals. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | 55 PA Code Chapter 2380.53(a)- Poisons ¿¿Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.¿
The Program Specialist is responsible to ensure that poisonous materials are kept locked or made inaccessible to individuals, when not in use per regulation 2380.53(a) ¿ Poisons.
The Program Specialists and Direct Service Workers were trained in the requirements of regulation 2380.53(a). (Attachment # 37-Training sheet & Attachment # 38- Memo)
Upon discovery during licensing, the large container of laundry detergent by the washer and dryer in area 1 was removed from the program. All laundry detergent will be locked up/made inaccessible. |
09/13/2017
| Implemented |
| 2380.53(b) | Repeat 8/16/16: A green spray bottle containing dish soap was found in the right upper kitchen cabinet in area 1. | Poisonous materials shall be stored in their original, labeled containers. | 55 PA Code Chapter 2380.53(b)- Poisons ¿¿Poisonous materials shall be stored in their original, labeled containers.¿
The Program Specialist is responsible to ensure that poisonous materials are stored in their original, labeled containers per regulation 2380.53(b) ¿ Poisons.
The Program Specialists and Direct Service Workers were trained in the requirements of regulation 2380.53(b). (Attachment # 37-Training sheet & Attachment # 38- Memo)
Upon discovery during the licensing inspection, the spray bottle containing dish soap was removed from the program. |
09/13/2017
| Implemented |
| 2380.87(b) | Repeat 8/16/16: Individual #5 is deaf and blind. He/She did not have a device to allow him/her to be alerted in the event of a fire. | 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. | 55 PA Code Chapter 2380.87(b)- Fire Alarms ¿¿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.¿
The Director and Program Specialist is responsible to ensure that individuals or staff that is 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 per regulation 2380.87(b) ¿ Fire Alarms.
The Program Specialists were trained in the requirements of regulation 2380.87(b). (Attachment # 39-Training sheet & Attachment # 40- Memo)
Due to Individual #5¿s severe hearing loss and blindness, the individual requires total staff assistance to evacuate during a fire drill, actual fire or other emergency. A mechanical device was ordered to alert Individual #5 in the event of a fire. (Attachment # 41 - Receipt) In addition, when the fire alarm is sounded, staff taps Individual #5 on the shoulder to alert him there is a fire or drill. Then staff physically assists Individual #5 ( into a wheelchair and pushes the wheelchair to exit the building.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017 |
11/30/2017
| Implemented |
| 2380.111(a) | Individual #1 had his/her physical on 4/15/16 and not again until 6/2/17. Individual #2 had his/her physical on 3/14/16 and not again until 5/9/17. Physicals for both individuals were not completed annually. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 55 PA Code Chapter 2380.111(a)- Individual Physical Examination ¿ ¿Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.
The Program Specialist is responsible to ensure that each individual has a physical examination within 12 months prior to admission and annually thereafter, (within one year of when the physical examination was completed) per regulation 2380.111(a). The Program Specialists were trained in the requirements of regulation. (Attachment #42- Training sheet & Attachment #43- Memo)
Individual #1 had his/her physical on 4/15/16 and not again until 6/2/17. Individual #2 had his/her physical on 3/14/16 and not again until 5/9/17. Physicals for both individuals were not completed annually.
Individual #3's annual physical is due by 10/26/2017. A memo was sent on 08/08/2017 to his family/residential provider as a reminder of when the physical is due for 2017. (Attachment - Memo #44 and Attachment #45 ¿ Physical)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.111(c)(3) | Repeat 8/16/16: Individual #2's physical completed on 5/9/17 indicated that he/she last had immunizations administered on 1/17/07. Individual #2's immunizations were due 1/17/17. Individual #3's physical dated 9/28/16 did not indicate any immunizations were administered. This area was left blank on the physical. Individual #4's physical completed on 6/29/17 indicated that he/she last had an immunization of diptheria administered in 1998 and tetanus administered in 2009. The Diptheria immunizations were due in 2008. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | 55 PA Code Chapter 2380.111(c)(3)- Individual Physical Examination ¿ ¿The physical examination shall include: Immunization as recommended by the United States Public Health Service, Centers for Disease Control.¿
The Program Specialist is responsible to ensure that each physical examination includes immunizations as recommended by the United States Public Health Service, Centers for Disease Control. Only Diphtheria immunizations are required. Diphtheria and tetanus must be given at least once every 10 years per regulation 2380.111(c)(3). The Program Specialists were trained in the requirements of regulation. (Attachment #41- Training sheet & Attachment #42- Memo)
Upon receipt of the Individual¿s Physical Examination, the Program Specialist will review the Individual¿s Physical Examination, Individual Support Plan, Assessment, Emergency Care and Member Profile forms for completeness and consistency in all documents using the Physical Checklist form. If information is inconsistent, the Program Specialist will contact the Parent/Family, Residential Provider and/or Physician to ensure accurate and consistent information is retained in the individual record. After the Physical Examination has been reviewed the Program Specialist will initial and date the bottom section of the Checklist indicating that all forms were reviewed for accuracy and consistency. Upon completion, the checklist will be attached to the physical examination.
The Program Specialists were trained on how to complete the Physical Examination Checklist form. (Attachment #46- Training sheet, Attachment #47- Memo and Attachment #48 - Physical Examination Checklist form)
Individual #2's physical completed on 5/9/17 indicated that he/she last had immunizations administered on 1/17/07. Individual #2's immunizations were due 1/17/17. Individual #2 (CS) terminated services on 09/22/2017.
Individual #3's physical dated 9/28/16 did not indicate any immunizations were administered. This area wa |
11/30/2017
| Implemented |
| 2380.111(c)(5) | Repeat 8/16/16: Individual #3 had a tuberculin test read on 4/16/15 and not again until 6/2/17. Individual #2 had a tuberculin test read on 5/1/15 and no documentation was found for another tuberculin test. One was due on 5/1/17. Individual #1 had a tuberculin test read on 6/15/16 however there was no documentation in the record of a tuberculin test prior to 6/15/16. | 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. | 55 PA Code Chapter 2380.111(c)(5)- Individual Physical Examination ¿ ¿The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.¿
The Program Specialist is responsible to ensure that each physical examination includes tuberculin skin testing with negative results every two years: or, if the tuberculin skin test is positive, an initial chest x-ray with results noted. If skin testing is positive, only an initial chest x-ray is required. Repeated chest x-rays are not required unless symptoms of tuberculosis occur such as coughing, unexplained weight loss, or night sweats per regulation 2380.111(c)(5).
The Program Specialists were trained in the requirements of regulation. (Attachment #42- Training sheet & Attachment #43- Memo)
Individual #3 had a tuberculin test read on 4/16/15 and not again until 6/2/17.
Individual #2 had a tuberculin test read on 5/1/15 and no documentation was found for another tuberculin test. One was due on 5/1/17. Individual #2 terminated services on 09/22/2017.
Individual #1 had a tuberculin test read on 6/15/16 however there was no documentation in the record of a tuberculin test prior to 6/15/16. Individual #1 The physical examination was updated to include the previous tuberculin skin testing date. (Attachment #51- Physical Examination)
The Program Specialist is responsible to ensure that the physical examination checklist is completed upon receipt of a physical examination form. The Program Specialists were trained on how to complete the Physical Examination Checklist form. (Attachment #46- Training sheet, Attachment #47- Memo and Attachment #48 - Physical Examination Checklist form)
Individual #1 The physical examination checklist was completed. (Attachment #52- Physical Examination Checklist)
Program Specialists are in the process of reviewing their caseloads to ensu |
11/30/2017
| Implemented |
| 2380.111(c)(7) | Individual #3's physical dated 9/28/16 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This area of the physical was left blank. | 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. | 55 PA Code Chapter 2380.111(c)(7)- Individual Physical Examination ¿¿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.¿
The Program Specialist is responsible to ensure that each physical examination includes an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals per regulation 2380.111(c)(7).
The Program Specialists were trained in the requirements of regulation. (Attachment #42- Training sheet & Attachment #43- Memo)
Individual #3's physical dated 9/28/16 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This area of the physical was left blank.
The physical examination was updated to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. (Attachment #49- Physical Examination) Individual #3 The physical examination checklist was completed. (Attachment #50- Physical Examination Checklist)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.111(c)(10) | Repeat 8/16/16: Individual #3's physical dated 9/28/16 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 55 PA Code Chapter 2380.111(c)(10)- Individual Physical Examination ¿¿The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.¿
The Program Specialist is responsible to ensure that each physical examination includes Medical information pertinent to diagnosis and treatment in case of an emergency per regulation 2380.111(c)(10).
The Program Specialists were trained in the requirements of regulation. (Attachment #42- Training sheet & Attachment #43- Memo)
Individual #3's physical dated 9/28/16 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical was left blank.
The physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency. (Attachment #49- Physical Examination) Individual #3 The physical examination checklist was completed. (Attachment #50- Physical Examination Checklist)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.111(c)(11) | Individual #3's physical dated 9/28/16 did not indicate special instructions for an individual's diet. This section was left blank. | The physical examination shall include: Special instructions for an individual's diet. | 55 PA Code Chapter 2380.111(c)(11)- Individual Physical Examination ¿¿The physical examination shall include: Special instructions for an individual's diet.¿
The Program Specialist is responsible to ensure that each physical examination includes special instructions for an individual's diet per regulation 2380.111(c)(11).
The Program Specialists were trained in the requirements of regulation. (Attachment #42- Training sheet & Attachment #43- Memo)
Individual #3's physical dated 9/28/16 did not indicate special instructions for an individual's diet. This section was left blank.
The physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency. (Attachment #49- Physical Examination) Individual #3 The physical examination checklist was completed. (Attachment #50- Physical Examination Checklist)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.128(a) | Staff #1 passed medications after his/her annual recertification date expired on 8/3/17. Staff #1 was not receritified to pass medications after 8/3/17. | 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. | 55 PA Code Chapter 2380.128(a)- Medication Administration Training ¿ ¿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.¿
The Medication Administration Trainer is responsible to ensure the medication administration staff receives annual re-certification in a timely manner to continue to pass medications to program participants.
The Medication Administration Trainer was trained in the requirements of regulation 2380.128(a). (Attachment # 32-Training sheet & Attachment # 33- Memo)
At the time of discovery, Staff #1 was immediately not permitted to pass medications. It should be noted that Staff #1 is no longer employed by Suncom Industries, Inc. An annual recertification of a 2380 medication administration staff person was completed in a timely manner. (Attachment #34- Summary Certification form)
The Medication Administration Trainers reviewed records to ensure compliance with this regulation. |
10/18/2017
| Implemented |
| 2380.128(c) | Staff #1 Completed medication administration training on 8/3/16 and not again in 2017. | Medications administration training of staff persons shall be conducted by an instructor who has completed and passed the Medications Administration Course for trainers and is certified by the Department to train staff persons. | 55 PA Code Chapter 2380.128(c) Medication Administration Training ¿ ¿Medications administration training of staff persons shall be conducted by an instructor who has completed and passed the Medications Administration Course for trainers and is certified by the Department to train staff persons.¿
The Medication Administration Trainers are responsible to ensure their certificates are renewed every three years.
The Medication Administration Trainer was trained in the requirements of regulation 2380.128(c). (Attachment # 32-Training sheet & Attachment # 33- Memo)
The Medication Administration Trainers who teach the Medication Administration Course at SUNCOM are certified. (Attachment #35 - Certificate and Attachment #36 - Certificate) |
10/18/2017
| Implemented |
| 2380.128(e) | Staff #3 signed off on Staff #2's medication administration training as observing all four med passess. There was no complete medication admininstration observer packet availalbe for Staff #3. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | 55 PA Code Chapter 2380.128(e)- Medication Administration Training ¿ ¿Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.¿
The Medication Administration Trainers are responsible to ensure the required documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons are kept in and accessible.
The Medication Administration Trainer was trained in the requirements of regulation 2380.128(e). (Attachment # 32-Training sheet & Attachment # 33- Memo)
It should be noted that SUNCOM does not have any Medication Administration Practicum Observers, therefore all training and documentation is completed by the Medication Administration Trainers as indicated previously.
The Medication Administration Trainers reviewed records to ensure compliance with this regulation. |
10/18/2017
| Implemented |
| 2380.176(a) | Individuals records stored in the filing cabinet in area 1 were left unlocked and unattended. | Individual records shall be kept locked when they are unattended. | 55 PA Code Chapter 2380.176(a)- Access ¿ Individual records shall be kept locked when they are unattended.
It is the responsibility of the all staff to ensure compliance with this regulation and ensure that individual records are kept confidential and locked when unattended.
All staff was trained in the requirements of regulation 2390.176(a). (Attachment # 30 -Training sheet & Attachment # 31 - Memo) |
10/20/2017
| Implemented |
| 2380.181(e)(4) | The supervision for Individual #3 in the community and day program was not clear in his/her assessment completed on 1/29/17. The supervision section stated that Individual #3 "requires 1:1 assistance and supervision while receiving services at SUNCOM and should remain within line of sight, however he/she can be unsupervised for up to 15 minutes at a time both in the SUNCOM building and while out in the community". | The assessment must include the following information: The individual¿s need for supervision. | 55 PA Code Chapter 2380.181(e)(4) ¿ Assessment -The assessment must include the following information: The individual¿s need for supervision.
It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client¿s Assessment, specifically the individual¿s need for supervision, per regulation 2380.181 (e)(4). ¿ Assessment.
Supervision levels in Assessments should be written in a manner that clearly and concisely identifies an individual¿s supervision level.
The Program Specialists were trained in the requirements of regulation 2380.181(e) (4). (Attachment # 23 -Training sheet & Attachment # 24 - Memo)
The supervision for Individual #3 in the community and day program was not clear in his assessment completed on 01/29/2017. The supervision section stated that Individual #3 "requires 1:1 assistance and supervision while receiving services at SUNCOM and should remain within line of sight, however he/she can be unsupervised for up to 15 minutes at a time both in the SUNCOM building and while out in the community".
An Assessment Addendum was completed for Individual #3, revising the 01/29/2017 Assessment clarifying the individual¿s need for supervision. (Attachment # 25 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(7) | Individual #2's assessment completed on 4/28/17 did not include his/her ability to move away from heat sources. | 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. | 55 PA Code Chapter 2380.181(e)(7) ¿ Assessment -The assessment must include the following information: The individual¿s knowledge of the dangers of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated.
The Program Specialist is responsible to ensure each assessment includes the individual¿s knowledge of the dangers of heat sources and ability to sense and move away from heat sources quickly. This regulation applies even if all heat sources exceeding 120 degree F within the facility are insulated. The Program Specialists were trained in the requirements of regulation 2380.181(e)(7). (Attachment #23- Training sheet & Attachment #24- Memo)
Individual #2's assessment completed on 4/28/17 did not include his/her ability to move away from heat sources. Individual #2 terminated services on 09/19/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(10) | Individual #3's assessment sent on 1/29/17 did not include his/her lifetime medical history. The lifetime medical history attached to the assessment was dated 6/1/17. | The assessment must include the following information: A lifetime medical history. | 55 PA Code Chapter 2380.181(e)(10) ¿Assessment - The assessment must include the following information: A lifetime medical history.
The Program Specialist is responsible to ensure the lifetime medical history is attached to the assessment per regulation 2380.181 (e)(10). ¿ Assessment.
The Program Specialists were trained in the requirements of regulation 2380.181(e) (10). (Attachment # 23 -Training sheet & Attachment # 24 - Memo)
Individual # 3¿s Assessment was updated to include current lifetime medical history. (Attachment #26 ¿ Assessment) The Lifetime Medical History was attached to the Assessment and the current Physical. The assessment addendum was sent to the Supports Coordinator and plan team members.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(13)(i) | Individual #3's assessment completed on 1/29/17 and Individual #2's assessment completed on 4/28/17 did not include progress and growth in the area of health. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health. | 55 PA Code Chapter 2380.181(e)(13)(i) ¿Assessment - The assessment must include the individual¿s progress over the last 365 calendar days and current level in the following area: (i) Health.
The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13)(i) ¿ Assessment.
The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, v and vi). (Attachment # 23-Training sheet & Attachment #24- Memo)
An Assessment Addendum was completed for Individual #3 revising the 01/29/2017 Assessment clarifying his progress and growth over the last 365 calendar days in the areas of health. (Attachment # 27 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members.
Individual #2's assessment completed on 4/28/17 did not include progress and growth in the area of health. Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(13)(ii) | Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the areas of motor and communication skills. | 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. | 55 PA Code Chapter 2380.181(e)(13)(ii) ¿Assessment - The assessment must include the individual¿s progress over the last 365 calendar days and current level in the following area: (ii) Motor and Communication skills.
The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13)(ii) ¿ Assessment.
The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, v and vi). (Attachment # 23-Training sheet & Attachment #24- Memo)
Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the areas of motor and communication skills. Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(13)(iii) | Individual #3's assessment completed on 1/29/17 and Individual #2's assessment completed on 4/28/17 did not include progress and growth in the area of personal adjustment. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | 55 PA Code Chapter 2380.181(e)(13)(iii) ¿Assessment - The assessment must include the individual¿s progress over the last 365 calendar days and current level in the following area: (iii) Personal Adjustment.
The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13)(iii) ¿ Assessment.
The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, v and vi). (Attachment # 23-Training sheet & Attachment #24- Memo)
An Assessment Addendum was completed for Individual #3 , revising the 01/29/2017 Assessment clarifying his progress and growth over the last 365 calendar days in the areas of personal adjustment. (Attachment # 28 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members.
Individual #2's assessment completed on 4/28/17 did not include progress and growth in the area of personal adjustment Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the area of socialization. | 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. | 55 PA Code Chapter 2380.181(e)(13)(iv) ¿Assessment - The assessment must include the individual¿s progress over the last 365 calendar days and current level in the following area: (iv) Socialization.
The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13)(iv) ¿ Assessment.
The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, v and vi). (Attachment # 23-Training sheet & Attachment #24- Memo)
Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the area of socialization. Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(13)(v) | Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the area of recreation. | 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. | 55 PA Code Chapter 2380.181(e)(13)(v) ¿Assessment - The assessment must include the individual¿s progress over the last 365 calendar days and current level in the following area: (v) Recreation.
The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13)(v) ¿ Assessment.
The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, v and vi). (Attachment # 23-Training sheet & Attachment #24- Memo)
Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the area of recreation. Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(13)(vi) | Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the area of 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. | 55 PA Code Chapter 2380.181(e)(13)(vi) ¿Assessment - The assessment must include the individual¿s progress over the last 365 calendar days and current level in the following area: (vi) Community Integration.
The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13)(vi) ¿ Assessment.
The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, v and vi). (Attachment # 23-Training sheet & Attachment #24- Memo)
Individual #2's assessment completed on 4/28/17 did not include his/her progress and growth in the area of community-integration. Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.181(e)(14) | Repeat 8/16/16: Individual #1's assessment completed on 10/8/16 does not indicate his/her ability to swim. Individual #2's assessment completed on 4/28/17 does not indicate his/her ability to swim. Individual #3's assessment completed on 1/29/17 does not indicate his/her ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | 55 PA Code Chapter 2380.181(e)(14) ¿Assessment - The assessment must include the individual¿s knowledge of water safety and ability to swim.
The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(14) ¿ Assessment.
The Program Specialists were trained in the requirements of regulation 2380.181(e) (14). (Attachment # 23-Training sheet & Attachment # 24- Memo)
An Assessment was completed for Individual #1, clarifying his knowledge of water safety and ability to swim. (Attachment # 29 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members.
Individual #2's assessment completed on 4/28/17 does not indicate his/her ability to swim. Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.184(a)(1)(iii) | No direct care staff were present at Individual #1's annual Individual Support Plan meeting held on 1/6/17. No direct care staff were present at Individual #2's annual Individual Support Plan meeting held 7/5/17. | 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. | 55 PA Code Chapter 2380.184(a)(1)(iii) ¿Plan Team Participation -¿A plan team must include as its members the following: (i) ¿ The individual, (ii) ¿ A program specialist or family living specialist, as applicable, from each provider delivering service to the individual, (iii) ¿ A direct service worker who works with the individual from each provider delivering a service to the individual and (iv) ¿ Any other person the individual chooses to invite. It is the Program Specialist¿s responsibility to ensure that the direct service worker participates in the development of the Individual Support Plan, including the annual updates and revisions.
The Program Specialist is responsible to participate in the development of the Individual Support Plan, including the annual updates and revisions under 2380.186 (relating to ISP review and revision). The Program Specialist was trained in the requirements of regulation 2380.184(a)(1), specifically (iii). (Attachment # 20 -Training sheet & Attachment # 21 - Memo)
If the direct service worker is unable to attend the meeting in person due to staffing issues or other unforeseen circumstances, they will complete the Input for ISP Planning Meeting form so their information can be shared at the meeting by the Suncom Program Specialist. (Attachment #22 ¿ form) |
11/30/2017
| Implemented |
| 2380.186(a) | Individual #3 had an ISP review completed on 6/27/16 and not again until 3/27/17. An ISP review was due on 9/27/16 and 12/27/16. | 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. | 55 PA Code Chapter 2380.186(a) ¿ISP review and revision- The ISP review must include the following: ¿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.¿
The Program Specialist is responsible to ensure that the Individual Support Plan (ISP) Reviews occur at least every 3 months to remain compliant with regulation 186(a). The Program Specialists were trained in the requirements of regulation 2380.186(a). (Attachment # 1-Training sheet & Attachment # 2- Memo)
Individual #3 had an ISP review completed on 06/27/2016 and not again until 03/27/2017. An ISP review was due on 09/27/2016 and 12/27/2016. In accordance with this regulation, Individual #3 had ISP reviews completed on 06/27/2017 and 09/27/2017. (Attachments #3 ¿ ISP Review 06/27/2017 and Attachment #4 ¿ ISP Review 09/27/2017)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |
| 2380.186(c)(1) | Individual #1's Individual Support Plan (ISP) reviews dated 6/20/17, 3/20/17, 12/20/16 and 9/20/16 did not indicate progress toward his/her outcome. Individual #2's ISP reviews dated 6/8/17, 3/8/17, 12/8/16 and 9/8/16 did not indicate progress toward his/her outcome. Individual #3's ISP reviews dated 6/27/17 and 3/27/17 did not indicate progress on his/her outcome. Individual #4's ISP reviews dated 6/19/17, 3/17/17, 12/16/16 and 9/16/16 did not indicate progress on his/her outcome. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | .55 PA Code Chapter 2380.186(c)(1) ¿ISP review and revision- The ISP review must include the following: (c)(1) A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months towards ISP outcomes supported by services provided by the facility licensed under this chapter.
The Program Specialists are responsible to ensure that the Individual Support Plan (ISP) Review includes a review of each section of the ISP, progress toward their outcome. The Program Specialists were trained in the requirements of regulation 2380.186(c)(1)(2). (Attachment # 5-Training sheet & Attachment # 6- Memo)
Individual #1's Individual Support Plan (ISP) reviews dated 06/20/2017, 03/20/2017, 12/20/2016 and 09/20/2016 did not indicate progress toward his/her outcome. ISP Review Addendum notes were completed to include documentation of the individual¿s progress toward her outcome for the ISP Reviews for 06/20/2017, 03/20/2017, 12/20/2016 and 09/20/2016. (Attachment # 7 ¿ 06/20/2017 ISP Review Addendum, Attachment # 8 - 03/20/2017 ISP Review Addendum, Attachment # 9 - 12/20/2016 ISP Review Addendum and Attachment # 10 - 09/20/2016 ISP Review Addendum)
An e-mail was sent to the Supports Coordinator for Individual # 1 ¿ notifying them of the revisions. (Attachment # 11 ¿ E-mail)
Individual #2's (CS) ISP reviews dated 06/08/2017, 03/08/2017, 12/08/2016 and 09/08/2016 did not indicate progress toward his/her outcome. Individual #2 terminated services on 09/22/2017.
Individual #3's (JS) ISP reviews dated 06/27/2017 and 03/27/2017 did not indicate progress on his/her outcome. ISP Review Addendum notes were completed to include documentation of the individual¿s progress toward his outcome for the ISP Reviews for 06/27/2017 and 03/27/2017. (Attachment # 12 ¿ 06/27/2017 ISP Review Addendum and Attachment # 13 - 03/27/2017 ISP Review Addendum)
An e-mail was sent to the Supports Coordinator for Individual # 3 ¿ notifying them of the revisions. (A |
11/30/2017
| Implemented |
| 2380.186(c)(2) | Repeat 8/16/16: Individual #2's ISP reviews dated 6/8/17, 3/8/17, 12/8/16 and 9/8/16 do not review his/her vagus nerve stumulation or seizure protocols. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | 55 PA Code Chapter 2380.186(c)(2) ¿ISP review and revision- The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.
The Program Specialists are responsible to ensure that the Individual Support Plan (ISP) Review includes a review of each section of the ISP. The Program Specialists were trained in the requirements of regulation 2380.186(c)(1)(2). (Attachment # 5-Training sheet & Attachment # 6- Memo)
Individual # 2¿s ISP reviews dated 06/08/2017, 03/08/2017, 12/08/2016 and 09/08/2016 do not review his vagus nerve stimulation or seizure protocols. Individual #2 terminated services on 09/22/2017.
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2017. |
11/30/2017
| Implemented |