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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home was completed 4-16-16. The Certificate of Compliance has an expiration date of 6-9-16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Armstrong Care, Inc. will in-service all Program Specialists and all Supervisors on making sure a self-assessment of each home serving eight or fewer individuals is completed within 3 to 6 months prior to the expiration date of the Armstrong Care, Inc.`s certificate of compliance. This in-service was completed by July 29, 2016. Also, Armstrong Care, Inc. will remind all Program Specialists and Supervisors to begin completing the self-assessment from February 1st of each year and to be completed and turned in no later than February 28, of each year. This process will be monitored by the Program Specialist Manager and the Program Director in order to prevent similar deficiencies from reoccurring in the future. [Documentation of reviews shall be kept. (AS 9/20/16)]
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08/08/2016
| Implemented |
| 6400.46(h) | The Direct Service Worker #1 date of hire 4-7-16 and began working in the home with individuals on 4-11-16 and was trained in first aid techniques on 4-24-16. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. | Direct Service Worker #1 was trained at hiring 4/7/2016 before working with individuals in first aid techniques on a training video as per the regulation 6400.46(h) Program specialists and direct service workers and at least one-person in a vehicle while individuals are being transported by the home, shall be trained
before working with individuals in first aid techniques. Direct Service Worker #1 received training by a certified trainer on 04/24/2016 as per the regulation 6400.00.46(i) Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and
annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardiopulmonary resuscitation.
A new Staff Training Documentation checklist was implemented by Human Resources adding the items First Aid/CPR via the Training Video which is done prior to working with the individuals and then the Certification in CPR, First Aid and Heimlich Maneuver by a certified trainer. Human Resources Director will re-check all employee files to ensure that all required paperwork and documentation is completed on all new hires for Armstrong Care, Inc. [Documentation of reviews shall be kept. (AS 9/20/16)] |
08/08/2016
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served.
The thermometer was purchased at the local pharmacy while the site inspection was taking place. The Thermometer has been placed back into the First Aid Kit as of July 14, 2016 by Site Supervisor. All homes were inspected between July 14 - 15, 2016. The first aid kits at all other sites were found compliant, containing all required items.
Supervisors will train Direct care staff on proper procedure when items are missing from the first aid kit, which is to notify Supervisor immediately so that a replacement can be purchased and placed in the kit. In addition, ACI Safety Manager will check as a part of the monthly site inspections to ensure compliance. [Documentation of monthly site inspections shall be kept. (AS 8/18/16)] |
08/08/2016
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 admitted 7-8-13 did not receive fire safety training until 7-9-13. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | A new orientation checklist has been created and implemented. It will be used from 7-8-2014 forward, It includes instruction for new admissions of individuals to review Fire Safety Procedures, the day of admission. A copy of the new Orientation Checklist will be emailed. |
07/09/2014
| Implemented |
| 6400.141(c)(6) | Individual #1's physical examination completed 1/4/13 did not include Tuberculin skin test. Individual #1 was admitted to the home on 7-8-13. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | at least,12 months prior to admission to ACI, a completed physical, including a Tuberculin skin test will be given.
The Program Specialist has compiled a list of items that MUST be obtained PRIOR to admission. A copy of this checklist will be emailed. [Individual has obtained a Tuberculin skin test since admission. (CHG 7/28/14)] |
07/09/2014
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Criminal history checks for Staff #1 and Staff #2 were not submitted within 5 days of hire. The hire date for Staff #1 was 12-17-12, and the hire date for Staff #2 was 1-28-13. Partially Implemented/Adequate Progress. KD. 5-8-2013. | (a) An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Training was given to the staff who performs a Criminal History check on potential new hires, by the Agency CEO, to request the Criminal History check within 5 working days of a new hire. She is going to request the check upon receiving an Application for Employment so as to ensure a check being done in a timely manner. |
03/20/2013
| Implemented |
| 6400.181(e)(13)(vi) | The assessment for all individuals of this home did not address the area of recreation. Partially Implemented/Adequate Progress. KD. 5-8-2013. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (vi) Recreation.
| The section of Recreation has been added to individuals' annual assessments. Page of assessment added for recreation, sent to inspector by email.
Assessments of all individuals will be audited to ensure they contain the recreation component. (CHG 5-8-13) |
03/22/2013
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment to the plan team and SC. Partially Implemented/Adequate Progress. KD. 5-8-2013. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| A page has been added to assessment that explains that assessments are sent out to team members 30 days prior to ISP meeting. A copy of the page showing who received an assessment, and also an example of an assessment that was sent out and to whom, has been sent to inspector by email.
The program specialist will ensure that documentation showing all plan team members (including the Supports Coordinator) receive the Assessment in a timely manner. (CHG 5-8-13) |
03/22/2013
| Implemented |
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