Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216304 Renewal 12/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff Member 1 did not have a PA criminal background check requested within 5 days of their hire date of 10/24/22.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Staff 1 received an FBI check upon hire but not a PA Criminal History Check prior to working with individuals. On 12/19/22 we secured a PA Criminal History Check, attached. The background was clear indicating no record. (See attached 2380-1a). A "New Hire - Annual Checklist" has been developed to track required documentation. On day two of orientation all background checks required for new employees will be submitted by the HR Manager. (See attached 2380-1b). 12/19/2022 Implemented
2380.56The bathroom in the program area did not have working ventilation.Program areas, dining areas, kitchens, bathrooms and first aid rooms shall be ventilated by operable windows or mechanical ventilation such as fans or air conditioning.During inspection the bathroom in the program area did not have a working ventilation system. On 1/09/23 repairs were made to the ventilation system by Lor-Mar. (See attached 2380-2a, 2b, 2c). Weekly Maintenance Reviews will be conducted on the ventilation system by Facility Manager and documented on the PEP Weekly Maintenance Review document. (See attached 2380-2d). completed on 01/09/2023. 01/09/2023 Implemented
2380.59(b)The water in the restrooms was measured at 128.1*F.Hot water temperatures in areas accessible to individuals may not exceed 120°F.During inspection the water temperature measured 128.1F. On 12/16/22 the water temperature on the water heater was reduced to 120F. The temperature was measured again on Monday 12/19/22 and the temperature measured 102.7F. (See attached 2380-3a). During monthly fire drills, conducted by the Facility Manager, the water temperature will be checked. Water temperature check has been added to the fire drill document. (See attached 2380- 3b). 12/20/2022 Implemented
2380.91(a)Individual 2 was not reinstructed in general fire safety timely, last training was completed 10/19/2021 and current training completed 12/06/2022. Individual 3 was not reinstructed in general fire safety timely, last training was completed 10/19/201 and current training wasn't completed until 12/06/2022.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.Individuals 2 and 3 did not have current fire safety training. Prior training was on 10/19/21 and each should have been retrained prior to that date. Both were retrained on 12/06/22. (See attached 2380-4a, 4b). A Participant Checklist has been put in place to track Fire Safety Training for each individual who attends PEP. That checklist will be monitored and maintained by the Assistant Directors for each program. (See attached 2380-4c). Completed on 12/19/22. 12/22/1922 Implemented
2380.111(a)Individual 2 did not have a physical examination annually; previous examination was completed on 01/31/2020 and current exam was not done until 06/13/2022.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual 2 had an expired annual physical and PEP did not secure an updated one prior to her returning to program. Individual 2 had her annual physical on 06/13/22, it had then been updated by her PCP on 07/14/22. (See attached 2380- 5a, 5b). A Participant Checklist has been put in place to track annual physicals for each individual who attends PEP. That checklist will be monitored and maintained by the Assistant Directors for each program. (See attached 2380- 5c). Completed on 12/19/22. 12/19/2022 Implemented
2380.111(c)(5)TB skin test for Ind. 2 with negative results every 2 years was not completed. On the Annual Physical exam form dated 01/31/2020 the TB test was completed on 01/24/2019 and on the exam form dated 06/13/2022 it was not completed and states the test is not due this year 2022.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.Individual 2 had an expired annual physical / outdated TB Skin Test and PEP did not secure an updated one prior to her returning to program. Individual 2 had her annual physical on 06/13/22, updated on 07/14/22 and then on 08/02/22 individual 2 had a TB Screening with her PCP, read on 08/04/22 ¿ the results were negative. (See attached 2380-6a, 6b). A Participant Checklist has been put in place to track annual physicals for each individual who attends PEP. That checklist will be monitored and maintained by the Assistant Directors for each program. (See attached 2380-6c). Completed on 12/19/22. 12/19/2022 Implemented
2380.111(c)(10)Individual 3 - Information pertinent to diagnosis and treatment in case of an emergency was left blank on the annual physical form dated 04/27/22.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual 3¿s annual physical examination did not have emergency contact information listed on it. On 12/19/22 the document was updated to include his emergency contact information. (See attached 2380-7a, 7b). A Participant Checklist has been put in place to track annual physicals for each individual who attends PEP. That checklist will be monitored and maintained by the Assistant Directors for each program. (See attached 2380-7c). Completed on 12/19/22. 12/19/2022 Implemented
2380.113(a)Staff Member 2 has not had physicals every two years based on their two most recent physicals, dated 9/9/21 and 5/16/18. Staff Member 3 has not had physicals every two years based on their two most recent physicals, dated 7/24/18 and 9/21/21.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.Staff 2 and 3 had annual physical examinations that were out of compliance with regulations. Staff 2 had her physical on 09/09/21 (See attached 2380-8a, 8b, 8c, 8d) and staff 3 had her physical on 09/02/21 (See attached 2380-8e, 8f, 8g, 8h) ¿ both are now in compliance. A New Hire / Annual Checklist has been developed to track required documentation. Monthly reviews of the checklist will be conducted by the HR Manager to ensure compliance with annual physicals and other annual requirements. (See attached 2380-8i). completed on 12/16/22. 12/16/2022 Implemented
2380.173(1)(ii)Individual 1 individual record did not include hair color. Individual 2's record did not include the individual's hair color. Individual 3's record did not include identifying marks as this portion was left blank and the hair color was not listed.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The Individual Record for individual 1, 2, and 3 were incomplete (1, hair color, 2 hair color, 3 identifying marks). The Individual Cover Page for all three individuals has been updated to include the missing information. (See attached 2380-9a, 9b, 10a). A Participant Checklist has been put in place to track accurate completion of the Individual Record for each individual who attends PEP. That checklist will be monitored and maintained by the Assistant Directors for each program. (See attached 2380-9c). Completed on 12/20/22. 12/20/2022 Implemented
2380.173(1)(iv)Individual 1 individual record did not include their religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The Individual Record for individual 1 was religious affiliation). His Individual Cover Page has been updated to include the missing information. (See attached 2380-10a). A Participant Checklist has been put in place to track accurate completion of the Individual Record for each individual who attends PEP. That checklist will be monitored and maintained by the Assistant Directors for each program. (See attached 2380-10b). Completed on 12/20/22. 12/20/2022 Implemented
SIN-00166036 Renewal 11/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)There were Hazardous Chemicals in an unlocked cabinet located in the Golden Branch (senior room).Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Corrective action: Heather Kuzowsky will oversee and implement the Corrective action. On 11/06/19 the art materials from the community art class had been moved to an appropriate location with an operating lock in the Arts for Socialization area. The art class materials should not have been kept in the senior¿s program area and therefore were moved and staff was retrained on the protocol. Heather has trained all Golden Branch staff again on 12/10/19 in the Toxic and Hazardous material policy formulated last year. Staff was trained in July of 2019 and retrained again after the citation. The lock on the cabinet had broken and it was not reported. Training included how to report and request building repairs. Maintenance request forms are also available to staff so that items in disrepair can be reported to the correct supervisor. The Community Art program will now store the materials in the cabinets provided for that class away from the program area. Date of completion: 12/9/19 Documents attached: -Retraining records for the ¿Toxic Substances and Hazardous Material Policies¿ training Senior Branch -Training records for the art instructor 12/09/2019 Implemented
2380.63(a)All the windows throughout the agency doesn't have screens. Windows located in the resting restroom does not have a stopper which allows the window to open in it entirely.Windows, including windows in doors, shall be screened when windows or interior doors are open.Corrective action: Josh Butterline will be responsible for this corrective action. On 11/19/19 Maintenance manager, Josh Butterline, temporarily added a screw to block the window track to ensure the window could open only a portion of the way until a new Window Lock can be installed. New locks arrived on 12/11/19 and were installed 12/12/19. The locks allow the windows to open partially but can be removed if necessary. PEP has never had screens in the building and the windows do not allow for the addition of screens. The building is older and the windows were designed with stoppers to manage and limit the access. Date of completion: 12/12/19 Documents attached: -Order specs. -Photo of temporary screw - Photo of new lock 12/12/2019 Implemented
2380.67(a)Ceiling tile located in the Golden Branch Room was detached and coming away (causing hazard conditions)Furniture and equipment shall be nonhazardous, clean and sturdy.Corrective action: On 11/06, the tile was removed upon notice. Josh Butterline, Maintenance Manager, repaired the tile removing the old glue and replacing using construction adhesive. Date of completion: 11/19/19 Documents attached: -Photo of completed ceiling tile repair -Maintenance request 11/19/2019 Implemented
2380.70(d)First Aid located in the resting room did not contain the manual guide.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.Corrective action: Who: Josh Butterline Maintenance Manager. On 11/06/19, immediately following the inspection, the first aid kit was replenished with a user manual. An instruction manual is labelled the lid of the kit but is not transportable. PEP has now included the addition of first aid kit inventory list to each kit. This is to ensure inventory is identified and noted monthly during the regular maintenance inventory review. A list of regulatory items for each program is present in each kit. Each kit will be identified by a kit number and its location in the building and will be included in the monthly inventory inspections. The inspections will be completed by Josh Butterline, the maintenance manager. If Items are not present at the time of inspection, it will be noted on the updated Maintenance inventory form. Josh will notify the Director of any missing items so that they may be replenished or purchased. Date of completion: -Manual was added on 11/06/19 -Updated inventory list for each kit was place inside individual kits on 12/10/19. An updated Monthly inspection sheet was created on 12/12/19 to include the kit identification number, location and inventory. The new sheet was utilized and reviewed on 12/13/19. Josh will maintain logs monthly as part of the monthly maintenance inspection and fire drill. This protocol was put in place after the last monthly fire drill but before Decembers therefore it was done separately this month from the Firedrill-Maintenance inspection Documents attached: -Photo of replenished kit -Photo of regulatory requirement items for each kit -Training record regulations for Josh Butterline -Updated Monthly inventory to include the identification of the kits and items -inventory inspection for all kits complete for December 12/13/2019 Implemented
2380.111(c)(4)For Individual #2 the Annual Physical Examination Form dated 7/16/19 the Hearing Screening was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Who: Heather Kuzowsky will be following through with the completion of this Plan of Correction. How: PEP has updated the letter and the spreadsheet used to track Physicals. We have added TB dates to the spreadsheet as well. The initial spreadsheet was updated on 11/20/19 and the letter finalized 12/9/19. The individuals Caregiver has scheduled an appointment to meet with a new Dr. in January. However ,the insurance will not cover 2 physicals to be completed in 1 year. The individuals Dr. is no longer are available for updates at this time and she is scheduled to meet with the new Physician in January. Mom has been notified of the updated protocol and will be making an attempt to schedule a physical this week. PEP has suggested that he caregiver explore having the physical completed at a clinic. We have initiated a Protocall as follows: ¿ 90, 60, 30, 15 day notice ¿ 30 day notice of suspension if not received with-in four weeks of the date the physical expired ¿ 30 day notice of suspension with incomplete physicals ¿ Suspension if physical has not been received Date of completion: 12/xx/19 Documents attached: --Physical KL -Communication of updated Physical notice request -Current physical was sent home with highlighted areas of completion for the physician -Reminder letter update sent to the home -Spreadsheet update to include TB -Notice of update- training records Program Coordinator -communication with the team -original Physical dated 4/13/18 not 9/13/18 - Request of updated Physical with vision and hearing screening, as recommended. Date TBD. 12/16/2019 Implemented
2380.111(c)(5)For Individual #2 the Annual Physical Exam for 2018 looks to be altered for the Tuberculosis Date give and date read, Requested Agency to provide a copy of the 9/13/18 exam.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.Who: Heather Kuzowsky will be following through with the completion. How: PEP has updated the letter and the spreadsheet used to track Physicals. We have added TB dates to the spreadsheet as well. The initial spreadsheet was updated on 11/20/19 and the letter finalized 12/9/19. The individuals Caregiver has scheduled an appointment for a new physical to update the one completed on 7/16/19. The individuals Dr. is no longer are available for updates at this time and she is scheduled to meet with the new Physician in January. Mom has been notified of the updated protocol and will be making an attempt to schedule a physical this week. We have initiated a protocol as follows: ¿ 90, 60, 30, 15 day notice ¿ 30 day notice of suspension if not received with-in four weeks of the date the physical expired ¿ 30 day notice of suspension with incomplete physicals ¿ Suspension if physical has not been received New evidence found on 12/16/19 suggests that the Physical date had been altered as suggested. Heather Kuzowsky received from Consortium Quality Department a copy of the physical and the physical and TB date were listed as 4/13/18. The SCO was alerted that the physical PEP has is dated as 9/13/18. The physicals appear to be the same other than the dates on the exam date and TB and a missing signature on the 9/13/18 physical were it was apparent on the 4/13/18 physical next to the TB results. The PEP team met and decided that we will add to the Book review process protocol to follow up with any possible discrepancies. A meeting was held on 12/16/19 to include Coordinators and it was agreed that Coordinators will follow up with errors or seemly corrected item lines. The PEP Program Coordinators and Directors will follow up with the PCP and SC to verify any documents that appear to be corrected. Date of completion: 12/16/19 Documents attached: -Physical KL -Communication of updated Physical notice request -Current physical was sent home with highlighted areas of completion for the physician -Reminder letter update sent to the home -Spreadsheet update to include TB -Notice of update, updated book review process and follow-up protocol- training records Program Coordinator -communication with the team - Original physical dated 4/13/18 not 9/13/18 provided by the SC - A request for a new physical is pending as the insurance will not cover 2 physicals in 1 year and the Dr.¿s office is not in operation any longer. 12/16/2019 Implemented
2380.111(c)(6)For Individual #2 Annual Physical Examination Form dated 7/16/19 the free of communicable diseases 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.Corrective action: Heather Kuzowsky, Director of Day Habilitation has been assigned responsibility for this correction. PEP has updated the letter and the spreadsheet used to track Physicals. We have added TB dates to the spreadsheet as well for additional reminders. The initial spreadsheet was updated on 11/20/19 and the letter finalized 12/9/19. The individual¿s Caregiver has scheduled an appointment for a new physical to update the one completed on 7/16/19. The individual¿s Dr. is no longer available for updates at this time and she is scheduled to meet with the new Physician in January. Mom has been notified of the updated protocol and will be making an attempt to schedule a physical this week. The insurance will not allow for 2 physicals in the same year and are not approving to be completed. PEP suggested exploring a clinic to complete the physical. We have initiated a protocol as follows: ¿ 90, 60, 30, 15 day notice ¿ 30 day notice of suspension if not received with-in four weeks of the date the physical expired ¿ 30 day notice of suspension with incomplete physicals ¿ Suspension if physical has not been received The PEP team met and decided that we will add to the Book review process protocol to follow up with any possible discrepancies. A meeting was held on 12/16/19 to include Coordinators and it was agreed that Coordinators will follow up with errors or seemly corrected item lines. The PEP Program Coordinators and Directors will follow up with the PCP and SC to verify any documents that appear to be corrected. Date of completion: 12/16/19 Documents attached: -Physical KL -Communication of updated Physical notice request -Current physical was sent home with highlighted areas of completion for the physician -Reminder letter update sent to the home -Spreadsheet update to include TB -Notice of update- training records Program Coordinator -communication with the team Original physical dated 4/13/18 not 9/13/18 - Physical update request to include that individual is free of communicable diseases. Updated letter and form was sent home. Appointment to be determined. Insurance will not allow for a second physical this year. 12/16/2019 Implemented
2380.111(c)(10)Information pertinent to diagnosis in case of emergency was left blank on Individual #2 annual physical exam dated 7/16/19.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Corrective action: Who: Heather Kuzowsky will be responsible for follow through with his matter. How: PEP has updated the notice letter to clarify expectations and the spreadsheet used to track Physicals. We have added TB dates to the spreadsheet as well. The initial spreadsheet was updated on 11/20/19 and the letter finalized on 12/9/19. We have initiated a protocol as follows: ¿ 90, 60, 30, 15 day notice ¿ 30 day notice of suspension if not received within four weeks of the date the physical expired ¿ 30 day notice of suspension with incomplete physicals ¿ Suspension if physical has not been received Mom has been notified of the updated protocol and will be making an attempt to schedule a physical with possibly a clinic to satisfy the regulations. Date of completion: 12/13/19 Documents attached: -Physical KL -Communication of updated Physical notice request -Current physical was sent home with highlighted areas of completion for the physician -Reminder letter update sent to the home -Spreadsheet update to include TB -Notice of update- training records Program Coordinator -communication with the team -original Physical from 4/13/18 not 9/13/18 -Updated Physical to include Medical information pertinent to diagnosis and treatment in case of an emergency. Mom is attempting to schedule a new physical. Insurance will not allow another Physical. PEP has suggested attempting exploring a clinic to complete in the meantime. 12/13/2016 Implemented
2380.111(c)(11)Special diet instructions was left blank on Individual #2 annual physical exam dated 7/16/19.The physical examination shall include: Special instructions for an individual's diet.Corrective action: Heather Kuzowsky will be responsible for the follow through action. How: PEP has updated the notice/reminder letter and the spreadsheet used to track Physicals. We have added TB dates to the spreadsheet as well. The initial spreadsheet was updated on 11/20/19 and the letter finalized 12/9/19. We have initiated a protocol as follows: ¿ 90, 60, 30, 15 days notice in advance of required date of annual physical ¿ 30 days notice of suspension if not received within four weeks of the date the physical expired ¿ 30 days notice of suspension with incomplete physicals ¿ Suspension if physical has not been received . When date of completion: 12/16/19 Documents attached: -Physical KL -Communication of updated Physical notice request -Current physical was sent home with highlighted areas of completion for the physician -Reminder letter update sent to the home -Spreadsheet update to include TB -Notice of update, change in book review check list and process - training records Program Coordinator -communication with the team -Copy of original physical from SC entity. It has appeared to be altered. Communication with the SCO. -Follow up correspondence in regards to special diet requests from Physician for KL. Spoke with KL¿s Mother and requested a new Physical be completed. The Supports Coordinator has sent a copy of this year¿s physical. They have put in a request for the original of the previous year to confirm the TB date. Mom reports that there is no way of contacting the PCP as the office has closed. Mom will attempt to follow up and get a new physical appointment. It was communicated by the SC on 12/13/19 that the insurance will not allow another physical within the same year. It was explained to mom that the physical was incomplete and why the physical needed to be repeated. If mom is unable to schedule an appointment to correct within 2 weeks¿ time a suspension letter can be sent until the physical is received. The individual¿s Caregiver has scheduled an appointment for a new physical to update the one completed on 7/16/19. The individual¿s Dr. is no longer available for updates at this time and she is scheduled to meet with the new Physician in January but the insurance will not allow for 2 physicals in 1 years time. Mom has been notified of the updated protocol and will be making an attempt to schedule a physical with possibly a clinic to satisfy the regulations 12/16/2019 Implemented
2380.181(a)For individual #2 the Annual Assessment was completed late, previous assessment was completed 12/04/2017 and current Assessment was completed 12/20/2018.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.Corrective action: Kelly Newton , Program Coordinator, was assigned responsibility for this corrective action. The Annual Assessment spreadsheet for this particular case load was updated on 12/07/19 to specify completion dates. As of 12/09/19, a new Program Coordinator has been assigned to the case and has been trained as of 12/12/19 on the annual assessment process. Date of completion: 12/12/19 KL Current assessment and previous years - Updated assessment spreadsheet sheet and master schedule - start sample - Training record of New Supports Coordinator Digo Kolingba 12/12/2019 Implemented
SIN-00162629 Unannounced Monitoring 09/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)Clean and sanitation conditions was not maintained in the women's restroom located on the main floor of the PEP facility. The stalls had debris related to ripped toilet paper, substance related to rust and dirt stains throughout the restroom floors, and in the toilets.Clean and sanitary conditions shall be maintained in the facility.Heather Kuzowsky was assigned to oversee the completion of the violation. Maintenance cleaned the area that day 9/13/19 by 12:00pm. on 9/28/19 cleaning agent was purchased and the rust was removed from the toilet area and floors. On 9/29/19 a new toilet seat was purchased and replaced. With the ceiling fully repaired this will hopefully prevent further rust from forming. 09/29/2019 Implemented
2380.56The women's restroom located on the main floor had no Ventilation such as a fan or air conditioning.Program areas, dining areas, kitchens, bathrooms and first aid rooms shall be ventilated by operable windows or mechanical ventilation such as fans or air conditioning.Heather Kuzowsky, Director of day habitation services was assigned the over site of the violation. the ceiling was removed. on 10/02/19, a return duct was installed along with the drop ceiling completion. Weekly maintenance inspections will be conducted in the program areas, dining areas, bathrooms and logs are available to report missing or equipment that is in disrepair. 10/02/2019 Implemented
2380.58(a)The ceiling located on the main floor women's restroom was not in good repair. There was a large hole in the ceiling exposing pipes and hanging wiring.Floors, walls, ceilings and other surfaces shall be in good repair.Heather Kuzowsky was identified to oversee correction of this violation. A plan of corrections had already been started to repair the ceiling. Several separate incidents had occurred that delayed the repair . on 7/11/19 a section of the ceiling had been removed due to an apparent leak. Josh opened the ceiling to dry the affected area. On 7/13/19, the hole was repaired with sheet rock and painted the same day. a week later on 7/22 another leak surfaced in the same area. The ceiling was removed again. The sheet rock needed to be repaired once again. this time the area of damage was larger. on 8/04/19 the ceiling was again replaced and spackled. on 8.11.19, the ceiling leaked again. on 8/23/19 , Aqua Plumbing was called to come out and replaced the cracked pipe in the mens bathroom on the second . The area was prepped for repair scheduled to start on 9/11/19. Due to a rescheduled vacation of maintenance manager Josh Butterline. Upon his return, he learned that his grandmother passed and the funeral was scheduled for 9/13/19. It was determined that a drop ceiling would be the best solution. Construction on the drop ceiling began and when near the completion an other leak emerged on 10/1/19 from the women's upstairs bathroom. Aqua Plumbing repaired the leak on 10/02/19 and the ceiling was completed. The drop ceiling was finalized and the leaks repaired on 10/2/19. The drop ceiling should satisfy easy access in the event that replacement or repairs are needed. 10/02/2019 Implemented
2380.58(b)The exposed hole located in the main level of the facilities women's restroom had exposed wires and not free of hazards. Example: falling debris, leaking.Floors, walls, ceilings and other surfaces shall be free of hazards.Heather Kuzowsky was identified to oversee correction of this violation. A plan of corrections had already been started to repair the ceiling. Several separate incidents had occurred that delayed the repair . on 7/11/19 a section of the ceiling had been removed due to an apparent leak. Josh opened the ceiling to dry the affected area. On 7/13/19, the hole was repaired with sheet rock and painted the same day. a week later on 7/22 another leak surfaced in the same area. The ceiling was removed again. The sheet rock needed to be repaired once again. this time the area of damage was larger. on 8/04/19 the ceiling was again replaced and spackled. on 8.11.19, the ceiling leaked again. on 8/23/19 , Aqua Plumbing was called to come out and replaced the cracked pipe in the mens bathroom on the second . The area was prepped for repair scheduled to start on 9/11/19. Due to a rescheduled vacation of maintenance manager Josh Butterline. Upon his return, he learned that his grandmother passed and the funeral was scheduled for 9/13/19. It was determined that a drop ceiling would be the best solution. Previous to completion on 10/1/19 the ceiling leaked again from a separate issue stemming from the women's upstairs bathroom. Aqua Plumbing was scheduled and completed the repair on 10/2/19. Josh Butterline completed the addition of the drop ceiling panels on 10/2/19.The drop ceiling will allow easy assessment and replacement of tiles if need be from future leaks. Bathrooms will not be accessible to the public prior to completed construction or repairs. Caution tape and signs will be posted to prohibited entrance. 10/02/2019 Implemented
2380.69(e)The women's restroom located on the main floor did not contain clean paper towels or an operational air hand dryer.Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.Heather Kuzowsky, Director of Day Habitation, was assigned to oversee the completion of this violation. The bathroom had been cleaned the previous day about 9:15 am. It had not yet been cleaned that morning. Night class does attend on Thursday evenings and the bathroom had not been cleaned or refilled this day. Heather Kuzowsky met with Josh Butterline the maintenance manager and reviewed the cleaning schedule. All soaps and paper towels should be replenished prior to scheduled program start time. Towels were refilled by 12:00pm this day 9/13/19. 09/13/2019 Implemented
SIN-00143866 Renewal 10/15/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)There were two bottles of chemicals found in a locked cabinet in the second-floor program space that did not have the ingredients of the chemicals in the bottles.Poisonous materials shall be stored in their original, labeled containers.Immediate Plan of Correction Items/Issues to Corrected: 1. The bottles were removed immediately. Maintenance staff and program directors were informed of this issue and directed to remove from the premises any bottles containing chemicals if the bottle does not have the original manufacturer¿s label. This was completed by 10/18/18. 2. Maintenance Manager ordered a new brand of spray cleaner that does not require mixing or pouring into other bottles and labeling them. This was completed by 10/31/18. Plan of Correction to Prevent Future Occurrences: 3. QA & Training Consultant created a new Policy & Procedure which was approved by Executive Director, Maintenance Manager, and Program Directors to inform all staff that any substances containing chemicals or toxins must be in their original bottle with the original manufacture's label and stored in locked cabinets. Any substances that are not in compliance must be removed immediately and may not be used by any staff in the facility. All staff were trained on this new policy by 12/14/18. 12/14/2018 Implemented
2380.67(a)There was a chair on the second-floor program area that had a missing arm pad. The chair was taken out of the area at the time of the inspection.Furniture and equipment shall be nonhazardous, clean and sturdy.Immediate Plan of Correction Items/Issues to Corrected: 1. The chair was removed from the program area at the time it was noticed during Licensing 10/17/18. Plan of Correction to Prevent Future Occurrences: 2. QA & Training Consultant created a new Policy & Procedure which was approved by Executive Director and Program Directors to ensure furniture and equipment is inspected regularly by program staff and Maintenance and that staff either immediately remove any furniture or equipment that is deemed hazardous, non-sturdy or unclean or report the issue to Maintenance immediately, so it can be removed immediately. Maintenance will conduct weekly inspections of program furniture and equipment in program areas. All Program Staff and Maintenance Staff have been trained on this new Policy and Procedure by 12/14/18. 12/14/2018 Implemented
2380.111(a)Individual #2"s annual physical dated 1/29/18 was more than a year from the previous exam which was done on 12/16/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Immediate Plan of Correction Items/Issues to Corrected: 1. The current Annual Physical which had been received was in place at the time of licensing although it had been received 15 days later than "grace" period allows. Insurance will not pay for a physical examination before same month and day of the previous physical examination. ODP allows a 15 day "grace" period in which Physical Examinations may occur before they are deemed late and out of compliance. Family could not schedule an appointment within the 15 day window; this is especially difficult around the holidays. Per our policy at the time of Licensing, Ninety-day reminder and 60-day reminder were sent to family warning that suspension may occur if next Physical is not completed by 1/29/19. A copy of the Annual Physical Form was hand-delivered to the family at the ISP Meeting on 10/26/18. 2. A review was conducted of the Master Schedule of due dates, including Physicals. Notices were sent, per our procedures at the time of Licensing. Plan of Correction to Prevent Future Occurrences: 3. A new Policy & Procedure was developed by QA & Training Consultant and approved by Executive Director and Program Directors to track 90-day, 60-day, 30-day Reminder notices to family/caregivers to help ensure Annual Physicals are completed no later than 15 days beyond the month and day of the previous year Physical. The new policy includes an additional 15-day notice. All Program Coordinators are required to document that notices were delivered by email or Postal services, and any follow-up calls are to be tracked in the existing Master Schedules for each caseload in the Shared Drive. The notices continue to caution that suspension will occur if Physicals are not completed on time. To date, PEP has not suspended any individual for a late Physical. Going forward, PEP will evaluate each case and may suspend if family/caregiver does not take reasonable measures to complete the Physical on time and suspension does not pose a great risk to individual or family. All Program Coordinators and Program Directors were trained on this new Policy & Procedure 12/12/18. 4. The Book/Record Review was updated by Jamie Kelly, QA & Training Consultant, to include a 15-day reminder about Annual Physicals and to make these notices more prominent on the checklist. Program Coordinators and Program Directors were trained on the new checklists 12/12/18. 12/12/2018 Implemented
2380.111(a)Individual #4's most current Annual physical Examination was completed on 02/08/2017.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Issues to be Corrected: 1. A current MA-51, dated 2/14/18, was in place at time of Licensing. This was provided by Supports Coordinator because the previous Program Coordinator was unable to obtain a copy of completed Physical from family on time. Unbeknownst to Program Coordinator and (apparently) Supports Coordinator at the time of Licensing, the MA-51 does not meet regulatory requirements. 2. The current Program Specialist called the individual's mother the day this document was deemed unacceptable by Licenser (10/16/18) and learned the individual coincidentally had a doctor appointment scheduled for the following day. Individual's mother agreed to ask the doctor to complete the physical. Program Specialist emailed the form to the family, and the doctor completed it the following day (10/17/18). Plan of Correction to Prevent Future Occurrences: 3. A new Policy & Procedure was developed by QA & Training Consultant and approved by Executive Director and Program Directors to track 90-day, 60-day, 30-day Reminder notices to family/caregivers to help ensure Annual Physicals are completed no later than 15 days beyond the month and day of the previous year Physical. The new policy includes an additional 15-day notice. All Program Coordinators are required to document that notices were delivered by email or Postal services, and document any follow-up calls are in the existing Master Schedules for each caseload in the Shared Drive. The notices continue to caution that suspension will occur if Physicals are not completed on time. To date, PEP has not suspended any individual for a late Physical. Going forward, PEP will evaluate each case and may suspend if suspension family/caregiver does not take reasonable measures to complete the Physical on time and suspension does not pose a great risk to individual or family.All Program Coordinators and Program Directors were trained on this new Policy & Procedure 12/12/18. 4. The Book/Record Review was updated by QA & Training Consultant, to include a 15-day reminder about Annual Physicals and to make these notices are more prominent on the checklist. Program Coordinators and Program Directors were trained on the new checklists 12/12/18. 5. Reminder Notices were updated to specify that an MA-51 will not meet the requirement for an Annual Physical. Program Coordinators will copy Support Coordinators on these notices when they are sent. Program Coordinators were trained on this new procedure on 12/12/18. 6. QA & Training Consultant updated the Annual Physical Form that is typically used by providers. The new form is easier to read due to new formatting. Some items are more clearly stated. Part 1 and Part 2 are more easily distinguished. Staff, family or caregiver's responsibility for completing Part 1 is more clearly described. Physician, or qualified person completing on behalf of the Physician is required to acknowledge he/she reviewed Part 1and corrected items as needed. There are reminders at the top of each page to complete every item by providing requested information or writing N/A or None, so it is clear that the item was not skipped over. This new form will replace old form in Shared Drive, and will be sent out with Reminder Notices for Annual Physicals'in place of old forms. Program Coordinators were trained on using this new form and reviewing the form on 12/12/18. 12/12/2018 Implemented
2380.111(c)(5)Individual #2's TB test was given on 1/29/18 but there was no date for reading and no result.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.Immediate Plan of Correction Items/Issues to Corrected: 1. On 10/16/18, Program Coordinator sent email to Supports Coordinator requesting results of TB, but was unable to obtain those results. A copy of the Annual Physical form was sent to family on 10/26/18 with a reminder to schedule a physical by 1/29/19. Plan of Correction to Prevent Future Occurrences: 2. QA & Training Consultant updated the Annual Physical Form that is typically used by providers. The new form is easier to read due to new formatting. Some items are more clearly stated. Part 1 and Part 2 are more easily distinguished. Staff, family or caregiver's responsibility for completing Part 1 is more clearly described. Physician,or qualified person completing on behalf of the Physician is required to acknowledge he/she reviewed Part 1and corrected items as needed. There are reminders at the top of each page to complete every item by providing requested information or writing N/A or None, so it is clear that the item was not skipped over. This new form will replace old form in Shared Drive, and will be sent out with Reminder Notices for Annual Physicals' in place of old forms. Program Coordinators were trained on using this new form and reviewing the form on 12/12/18. The TB test reading is clearly marked, and if it is left blank, it will be easily spotted by Program Coordinator. 12/12/2018 Implemented
2380.173(1)(ii)Individual #1's record did not include identifying marks. This was corrected during inspection.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Immediate Plan of Correction Items/Issues to Corrected: 1. Identifying marks were added to the Emergency Care/Cover Sheet on 10/16/18, the day this issue was noted by Licensor. Plan of Correction to Prevent Future Occurrences: 1. Program Coordinator, updated the template for the Emergency Card/Cover Sheet & posted to Shared Drive 10/16/18. 2. Program Coordinators, Kelly Newton & Carter Fitzgerald, updated the Cover Sheets for all consumers in the program, using the new template. All consumers¿ files were updated by 10/26/18. 3. The Book Review Checklist was updated by QA & Training Consultant, to include a note to ensure that the new Emergency Card/Cover Sheet is used. Program Coordinators and Program Directors were trained on the new checklists 12/12/18. 12/12/2018 Implemented
2380.173(1)(iii)Individual #1's record did not list primary language. This was changed during inspection.Each individual's record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English.Immediate Plan of Correction Items/Issues to Corrected: 1. Program Coordinator added primary language and mode of communication to Emergency Care/Cover Sheet on 10/16/18, the day this issue was noted by Licensor. Plan of Correction to Prevent Future Occurrences: 2. Program Coordinator updated the template for the Emergency Card/Cover Sheet and posted it to Shared Drive 10/16/18. Program Coordinators, Kelly Newton & Carter Fitzgerald, updated the Cover Sheets for all consumers on their caseload, using the new template. All consumers' files were updated by 10/26/18. 3. The Book Review Checklist was updated by QA & Training Consultant, to include a note to ensure that the new Emergency Card/Cover Sheet is used. Program Coordinators and Program Directors were trained on the new checklists 12/12/18. 12/12/2018 Implemented
2380.181(e)(13)(vi)Individual #3's annual assessment dated 2/12/18 did not include recommendations.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.Description of how non-compliance occurred: To improve the overall quality and usefulness of our Annual Assessments and ensure they met all the regulatory requirements, PEP designed new templates, and program coordinators used those templates to update Annual Assessments as they came due. This assessment that was cited was not yet due and had not been updated. Immediate Plan of Correction Items/Issues to Corrected: 1. Program Coordinator updated Annual Assessment using new template. This was completed by 12/13/18. On 12/13/18, QA & Training Consultant reviewed updated l Assessment and found it to meet all regulatory requirements. Updated Assessment was forwarded to the team on 12/13/18. 2. Program Coordinators identified other Annual Assessments not yet due but not updated to the new form. Identified Assessments not updated to new form. Updated those Assessments and forwarded them to the team by 12/13/18. Plan of Correction to Prevent Future Occurrences: 4. The new template which covers all regulatory requirements was replaced in our Shared Drive July 3, 2018, and all program coordinators were instructed to use that form as updates occurred. As noted above, program coordinators were instructed to update any Annual Assessments that had not yet been updated to the new format. That was completed by Program Coordinator 12/13/18. All Annual Assessments are currently written in the new format. 5. The Book Review Checklist was updated by QA & Training Consultant, to include a note to ensure that the new Assessment format was used for all current Annual Assessments and approved by Program Directors by 12/6/18. Program Coordinators and Program Directors were trained on the new checklists 12/12/18. 12/13/2018 Implemented
SIN-00113976 Renewal 04/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)Located on the floor on the Carlise side of the building 2nd floor as well as on the threshold leading to the 2nd floor men's bathroom a black substannce consistent with dirt.Clean and sanitary conditions shall be maintained in the facility.The metal threshold to the second floor bathroom with a black substance/dirt was addressed and removed by our maintenance dept. staff. 04/07/2017 Implemented
2380.58(a)The seond floor fire escape had several floor tiles missing or loose.Floors, walls, ceilings and other surfaces shall be in good repair.The missing and/or loose tiles in the second floor fire escape hallway were replaced by our maintenance dept. 04/07/2017 Implemented
2380.58(b)The 2nd floor kitchen hallway has an electrical box with exposed wires.Floors, walls, ceilings and other surfaces shall be free of hazards.The 12-volt electrical wires in the overhead transom in the second floor kitchen hallway are scheduled to be repaired by a subcontractor via our maintenance dept. 07/06/2017 Implemented
2380.111(a)Individual #2's physical was dated 12/15/16 became late since his previous one was completed 11/23/15,Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Individuals annual physical forms were received late. This becomes a problem because they are supposed to be received before the annual due date. Thus going forward Program Coordinators will send out reminder letters to the parents/ caregivers. At the regular Book Reviews at PEP, staff will have reminders to check off on the form to send letter to physician at 90 and 30 days out from due date. Letters will then be sent 90 days, and then again 30 days before the Physical form is due. If need be Program Coordinators will become proactive, and reach out to the physician¿s office to let them know as well. 04/05/2017 Implemented
2380.111(c)(6)Individual #2's physical dated 12/15/16 did not indicate whether he was free from communicable disease.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.The Individual¿s annual physical exam was not thoroughly filled out by the physician. The section asking if the person was clear and free of communicable diseases was not checked. Also the section asking about the individual¿s health maintenance was not check. In the future to avoid any oversight the Program Coordinator will send notes home to the parents/ caregivers 90 days, and 30 days before the physical is due. Our hopes are that we are able to receive the annual form in a timely manner, and completed in its totality. If necessary the Program Coordinators will reach out to the physician¿s office to let them know as well. 04/05/2017 Implemented
2380.111(c)(7)Individual # 2's physical dated 12/15/16 did not indicate healh maintenance needs. 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 Individual¿s annual physical exam was not thoroughly filled out by the physician. The section asking about the health maintenance needs, Medications, and blood work was not checked. In the future to avoid any oversight the Program Coordinator will send notes home to the parents/ caregivers 90 days, and 30 days before the physical is due. Our hopes are that we are able to receive the annual form in a timely manner, and completed in its totality. If necessary the Program Coordinators will reach out to the physician¿s office to let them know as well. 04/05/2017 Implemented
2380.111(c)(10)Individual #3's physical dated 7/7/16, individual #4's physical dated 1/20/17, individual #2's physical dated 12/16/16, and individual #5's physical dated 4/26/16 did not include information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The individuals¿ physical exams did not include medical information pertinent to diagnosis and treatment in case of an emergency. PEP program specialists routinely mail families a reminder when an individual¿s physical nears its due date. This letter will be amended to include a statement emphasizing the need for this information so that families can inform their physicians when they complete the form. If PEP receives a physical that does not include the information, it will be returned to the family with the request that they have the doctor complete the form. 04/05/2017 Implemented
2380.173(1)(iv)Individual #5's record did not record the individual's religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The individual¿s religious affiliation was not described in her record. Each record kept at PEP contains a cover sheet based on a template. This template does contain a line for religious affiliation. This individual is new to the 2380 program, and therefore her cover sheet is new. When creating the sheet, the program specialist neglected to complete that line. The program specialist has since created a new sheet that contains the information. The program specialist verified that all other files contained the information as well. 05/25/2017 Implemented
2380.181(a)Individual #5, d.o.a. 1/26/17, did not have an initial assessment on file 60 days after admission.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.The individual's file did not contain a 90-day assessment. This individual is primarily a participant in the 2390 program, however she is attending the 2380 program on a part-time basis (one day per week) to see if she likes it. Because the individual only attends the program on one day per week, the program specialist decided that the available data would not support a very strong 90-day assessment and that a more thorough evaluation could be done with more time. The program specialist now understands that there should not be any exceptions to the 90-day rule for any reason, and new enrollees henceforth will have their assessments completed at 90 days. The assessment for this individual was completed shortly after the licensing audit. 04/05/2017 Implemented
2380.181(c)Individual #1's assessment 9/16/16, individual #2's assessment 7/3/16 and individual #3's assessment 7/12/16 did not indicate the source of the assessments information.The assessment shall be based on assessment instruments, interviews, progress notes and observations.The individuals¿ assessments did not describe the sources of the information contained. Assessments for the ADT program are done on a template and updated annually. The template will be updated to include the sources of information used in each assessment (progress notes, ISP, observation, interview) in a statement on its cover. With use of the updated template, all future assessments will contain the information. 04/05/2017 Implemented
2380.181(d)Individual #2's asssessment dated 7/3/16 and individual #4's assessment dated 6/27/16 was not signed and dated by the program specialist.The program specialist shall sign and date the assessment.Both Individuals 90 day assessments were done during the appropriate quarter. However the Assessments were not signed and dated by the Program Coordinator. Also the Assessments need to include the contents sources (ISP, daily development notes, staff interaction). Moving forward to avoid said violation the Program Coordinator will keep an electronic Reminder file making sure that the Assessment is done on time signed and dated. 04/05/2017 Implemented
2380.183(4)Individual #3's ISP dated 11/9/16 did not inclde a reduction plan for his increased level of supervision.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 consumers ISP did not contain a fading plan for intensive staffing. The program specialist will create a fading plan for the 1:1 staffing and subsequently organize a team meeting so that the individuals supports coordinator can add that plan to his ISP. The program specialist will examine the ISPs of each consumer in the program who receives 1:1 supports to ensure that those ISPs also contain a fading plan. In the event that any do not, fading plans will be written for addition to those ISPs as well. The program specialist will be sure that these fading plans are updated annually at the individual's ISP meetings. 04/05/2017 Implemented
SIN-00084508 Renewal 10/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The second floor men's restroom had a rusty radiator cover. The electrical conduit line running under the sinks were rusted. Both stalls in the men's restroom were missing tiles near the flushing mechanism. The second floor women's restroom ceiling had water damage.Floors, walls, ceilings and other surfaces shall be in good repair.2380.58(a) The rusted radiator cover and the rusted electrical conduit cover under the sinks in the men's 2nd floor bathroom were ordered to be sanded and painted by PEP's maintenance dept. manager, Gus Nyekan, on 10/16/15. The maintenance department staff will conduct monthly physical site inspections, starting within 30 days of receipt of this plan of correction. [SW 11.23.15] 10/16/2015 Implemented
2380.67(a)There were two upholstered chairs, on the Carlisle St side of the program, with torn fabric.Furniture and equipment shall be nonhazardous, clean and sturdy.2380.67(a) Both upholstered chairs in the Adult Day program were replaced and the damaged chairs removed following the audit on 10/15/15 by the Programs Director, Robert Scott. The maintenance department staff will conduct monthly physical site inspection of the program to ensure the facility is in good repair. [SW 11.23.15] 10/15/2015 Implemented
2380.87(b)The second floor strobe light in the Broad Street room was very weak.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.2380.87(b) Although we have no hearing impaired individuals who might depend on the strobe light for fire safety in that area, the technician was contacted immediately by PEP's maintenance manager, Gus Nyekan and replacement of that weak strobe light was resolved on 10/22/15. The maintenace department staff will check the strobe light on a monthly basis during the monthly fire drills to ensure that all fire safety equipment is operating as required, starting within 30 days of receipt of this plan of correction. [SW 11.23.15] 10/22/2015 Implemented
2380.89(d)The fire drill logs, dated 9/22/14 and 10/27/14, indicated an evacuation time of 2 minutes and 40 seconds and 2 minutes and 35 seconds, respectively. The fire drill logs, dated 1/16/15 and 4/16/15, did not include the evacuation time.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.2380.89(d) Fire drill log of 9/22/14 indicated evacuation time of 2 mins. and 40 secs, 10 seconds over the prescribed time 0f 2:30. Fire drill log of 10/27/14 indicated evacuation time of 2 mins. and 35 secs, 5 seconds over the prescribed time. In the future, all fire drills that are not completed within the prescribed time will be redone within a week by PEP's fire marshal, Beth Ryan. If a continued pattern of not meeting the evacuation time occurs, the Programs Director, Robert Scott, in union with the respective program managers will review our census population for individuals whose physical limitations may necessitate retaining them in any of the building's fire safe zones. 10/16/2015 Implemented
2380.111(a)Individual #1 had a physical exam completed on 4/16/14 and not again until 6/9/15.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.2380.111(a) Individual #1 began his participation in the 2380 day program on 3/10/15, just 40 days short of requiring an updated physical from his prior exam date of 4/16/14. His family was notified of the requirement upon his admission, and again with regular phone calls thereafter but to no avail until 6/9/15. Every effort to communicate the need for updated physicals to families and other concerned representatives of individuals will be ongoing via written notifications, as well at our monthly parents meetings. The program director will ensure that all participants of the program complete an annual physical as required by this regulation. An audit of all participants records will be conducted by the Program Specialist to ensure that all physical examinations are completed annually, starting within 30 days of receipt of this plan of correction. [SW 11.23.15] 06/09/2015 Implemented
2380.111(c)(5)Individual #2 had a TB test completed on 6/4/13 and not again until 10/7/15.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.2380.111(c)(5) Individual #2 resides in a residential program and the day program must rely on them to provide us with an updated physical and TB test result every 2 years. We should have received the evidence of that exam by 6/4/5, but did not receive it until after 10/7/15. We are very reluctant to suspend a person for the failure of others to acquire the exam and test results. We will communicate more closely with all parties going forward to seek improved cooperation to avoid the need for a temporary suspension from program in the future in order to meet licensing requirements. The Program Director will ensure that all particpants, of the program, physical examination include the required TB tests every two years and will notify the residential program at least 30 days before the testing is due. A tracking form will be developed by the Program Specialist which includes the date of the annual physical and the dates of the TB tests for all participants of the program to ensure that the TB test and physical are completed timely, starting witin 30 days of receipt of this plan of correction.[SW 11.23.15] 11/16/2015 Implemented
2380.173(1)(v)Individual #2 had a photograph, dated 7/1/2010, that was not current.Each individual's record must include the following information: Personal information including: A current, dated photograph.2380.173 (1) (v) Although staff believed the photo on file was an accurate reflection of him, Individual #2 now has a new photograph on file (dated 10/16/15) and that photo is included in the attachments. The Program specialist will date all photos of participants to ensure that the photos are current and will audit all records to ensure they are compliant with this regulations, starting within 30 days of receipt of this plan of correction and annually thereafter. [SW 11.23.15] 10/16/2015 Implemented
2380.181(f)Individual #3's assessment, dated 12/6/2014, was not sent to the SC 3 30 days prior to the individual support plan meeting on 12/9/2014.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).2380.181 (f) Individual #3: Assessment not sent 30 days prior to ISP. The individual¿s assessment actually was sent 30 days prior to his ISP meeting. The auditor took issue with the fact that the assessment was done on 12/6/14 (or, annually after the initial admissions assessment), while the ISP meeting was held on 12/9/14. Therefore, the assessment that was sent to the Supports Coordinator 30 days prior to the meeting was dated 12/6/13, and therefore was just 11 months old. The Supports Coordinator was given the more recent assessment (12/6/14) at the aforementioned ISP meeting. As per the suggestion of the auditor, the individual's assessment date has now been moved up by approximately one month and has since been completed on 11/11/15. It will be sent to the Supports Coordinator 30 days before the next ISP meeting, which is likely to be scheduled very soon. The assessment referenced by the auditor as well as the newest assessment of 11/11/15 are being forwarded as attachments. The Program Specialist will provide all participants assessments 30 days prior to the SC and will develop a tracking form that includes the dates of the ISP meeting dates and the dates the annual assessments are completed then sent to the SC, starting within 30 days of receipt of this plan of correction. The tracking document will be reviewed monthly by the Supports Coordinator to ensure that all assessments are sent to the SC 30 days prior to the ISP meeting. [SW 11.23.15] 11/11/2015 Implemented
2380.184(a)The program specialist did not participate in the ISP revision meeting on 3/3/15.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).2380.184(1) The Individual is not identified in the citation. However, PEP's program specialist for Individual #3 did not schedule a ISP revision meeting within 90 days, as required. This was an oversight due in part to staff turnover in that position during the year. Management will ensure closer scrutiny in the future at our regular Book Review meetings that are scheduled each Wednesday. A ISP revision meeting with the team was scheduled for 11/17/15 but was then postponed last minute by the individual's family. We expect that a meeting will be rescheduled for the near future. The Program Director will conduct the ISP meeting for Invididual #3 within 30 days of receipt of this plan of correction. The Program Specialist will develop a tracking form to facilitate the tracking of all ISP meetings, within 30 days of receipt of this plan of correction. The tracking document will include the date of the ISP meeting, the date a letter was sent to the team members, the date the assessment was sent to the SC and the date of the assessment, to ensure that these meetings are conducted in accordance with the regulations. [SW 11.23.15] 11/17/2015 Implemented
SIN-00065305 Renewal 08/27/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #2 was admitted 1-30-14 and the initial assessment was not done until 5-20-14.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 #2: The individual's 60-day assessment was not completed in a timely manner by a former staff member. Their successor has completed the assessment after taking over that position in May 2014. Since that time, goals have been established with the individual's family and team and goals have been reported monthly, beginning in June of 2014. Quarterly reports have subsequently been written on 8/1/14 and again on 11/1/14 in accordance with the Annual Review Update Date written into the ISP. The individual's 2014-2015 annual assessment will be completed in March 2015 to ensure that all future documentation will be completed and filed on the proper dates. (Both the initial document and the corrected document are being submitted for your review.) 08/28/2014 Implemented
2380.186(c)(2)Individual #1 has a behavior support plan dated 11-16-13 that was not reviewed by the program specialist every three months.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Individual #1: The first quarterly report of 12/13/13, written shortly after the Behavioral Plan of 11/16/13 acknowledges utilization of the plan. But the next quarterly reports of 3/12/14 and 6/12/14 do not specifically mention the Behavioral Plan (nor the variables associated with his plan). Yet, the March report indicates an increase in problematic behaviors and the June report indicates an increase in positive behaviors. This was clearly an oversight and the staff who wrote those reports is no longer responsible for doing so. Following the licensing review in August, the successive quarterly report of 9/12/14 does specifically describe progress and staff implementation with respect to the Behavioral Plan. Moving forward, staff will properly reflect the implementation of the Behavioral Plan in the quarterly reports in order to thoroughly communicate his behavioral progress to the Supports Coordinator and the team. (The 9/12/14 quarterly report is being submitted for your review.) 08/28/2014 Implemented
SIN-00051816 Renewal 08/22/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(12)Indivdiual #1's assessment dated 8/31/12, individual #2's assessment dated 12/4/12, individual # 3's assessment dated 19/26/12 and individual # 4's assessment dated 10/4/12 did not include recommendations toward specific areas of training.(e)  The assessment must include the following information: (12)  Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Program director, R. Scott, will ensure that new staff are properly trained and familiar with the regulations, and we will regularly review the assessment tool in the files to ensure implementation and compliance with regulations. 10/18/2013 Implemented
2380.185(a)Individual's #1 ISP dated 3/3/13 was not implemented as written. An outcome to increase vocational skills to earn more money was not implemented.(a)  The ISP shall be implemented by the ISP'S start date.After team agreed to a program change for this individual that she should be transferred from vocational to day habilitation program, PEP's program specialist made multiple requests to have the ISP updated. In July 2012, the actual program transfer took place and in November, 2012 the team met and concurred that the change was appropriate. By March 13, 2013 the ISP implementation should have been completed. To date, a revision to the ISP has still not taken place, despite our continued reminders that it was still not updated. We will continue to make those requests. Email exchanges are attached. 10/21/2013 Implemented
2380.186(a)ISP reviews dated 6/19/13, 3/22/13, 12/24/12 and 9/14/12 did not indicate progress and growth for individual #1 outcome: to increase vocational skills to earn more money.(a)  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.PEP's program director will ensure that our program specialists will provide more description and detail in the quarterly reports to indicate progress and improvement on outcomes of goals. In addition, we will ensure greater detail about where and what occurred while in the community outings as it applies to the individual's community goal. (See attachment of most recent quarterly report.) 09/19/2013 Implemented