| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(h) | There was no documentation regarding the fire safety expert's credentials. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | We attempted to contact the Instructor that taught the Fire Safety Class in an effort to gain the needed credentials of the Fire Safety Instructor. We were unsuccessful in gaining said credentials from the company we utilized. It has been decide that a new Fire Safety instructor will be hired and credentials and training content will be received prior to the start of class instruction to ensure we are meeting said Fire Safety Training regulation. Documentation of the fire safety experts credentials will be sent to the Department within 30 days of receipt of this plan of correction [SW 11.18.15] |
11/02/2015
| Implemented |
| 2380.111(c)(4) | Individual #1's physical examination, dated 7/15/14, did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | A check off sheet will be developed that entails items that need to be present on the physical form for each individual in accordance to regulation 2380.111. Site Director and Program Specialist will be responsible for ensuring that each physical is filled out on accordance to the regulation statement. If the physical is not filled out in its entirety it will be given back to the individuals care person so that it can be completed by the Primary Care Physician in a timely manner. Individual #1's physical examination will be updated to include the require vision and hearing screening within 30 days of receipt of this plan of correction. The program specialist will review all participants physical examinations to ensure that they all have had a vision and hearing screen as part of their annual examination, within 30 days of receipt of this plan of correction. [11.18.15] |
11/02/2015
| Implemented |
| 2380.181(e)(5) | Individual #2's assessment, dated 12/30/14, did not include the ability to self administer medication. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Said individuals Assessment will have an addendum to the "ability to self-administer medications" section of the assessment. In the future, all assessments will be double checked for accuracy by both the Program Specialist and Site Director. A signature line will be added to the assessment that allows for the Site Director to acknowledge revision of the document. |
10/14/2015
| Implemented |
| 2380.181(e)(12) | Individual #2's assessment, dated 12/30/14, did not include recommendations for areas of training, vocational programming and community integrated employment. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The Program Specialist will be retrained on licensing regulations specifically regulation number 2380.181 that pertains to the content of information needed in an assessment. The Program Specialist will sign an acknowledgement form stating that they have been retrained on said document and content needed. The Program Specialist will update Individual #2's assessment to include all of the required elements of a complete assessment within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants assessments to ensure that all of the elements of the assessments are completed, within 30 days of receipt of this plan of correction. [SW 11.18.15] |
10/14/2015
| Implemented |
| 2380.181(e)(13)(i) | Individual #2's assessment, dated 12/30/14, 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. | The Program Specialist will be retrained on the regulations, specifically the regulation 2380.181 that entails information needed in the assessment document. The Program Specialist will sign an acknowledgement form stating they were retrained on the regulations pertaining to this document. The Program Specialist will update Individual #2's assessment to include all of the required elements of a complete assessment within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants assessments to ensure that all of the elements of the assessments are completed, within 30 days of receipt of this plan of correction. [SW 11.18.15] |
10/14/2015
| Implemented |
| 2380.181(e)(13)(ii) | Individual #2's assessment, dated 12/30/14, did not include progress and growth in the area of motor and communication skills. Individual #3's assessment, dated 10/7/14, did not include progress and growth in the area 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. | The Program Specialist will be retrained on the regulations by the Site Director. The information reviewed will target specifically the regulation 2380.181 that provides information on what is to be documented upon in the assessment document. An acknowledgement form will be signed by the Program Specialist that states retraining and understanding of what is required to be reported upon n said document. The Program Specialist will update Individual #2's assessment to include all of the required elements of a complete assessment within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants assessments to ensure that all of the elements of the assessments are completed, within 30 days of receipt of this plan of correction. [SW 11.18.15] |
10/14/2015
| Implemented |
| 2380.181(e)(13)(iii) | Individual #2's assessment, dated 12/30/14, did not include progress and growth in personal adjustment. Individual #3's assessment, dated 10/7/14, did not include progress and growth in 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. | The Program Specialist will be retrained on the regulations by the Site Director. Specific retraining will be given in regards to regulation 2380.181. An acknowledgement form will be signed by the Program Specialist stating that necessary document content of the assessment is understood. The Program Specialist will update Individual #2's assessment to include all of the required elements of a complete assessment within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants assessments to ensure that all of the elements of the assessments are completed, within 30 days of receipt of this plan of correction. [SW 11.18.15] |
10/14/2015
| Implemented |
| 2380.181(e)(13)(iv) | Individual #2's assessment, dated 12/30/14, did not include progress and growth in socialization.
Individual #3's assessment, dated 10/07/14, did not include progress and growth in 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. | The Program Specialist will be retrained by the Site Director on the content of the regulations specifically regulation 2380.181. This regulation specifies the necessary information that is to be reported upon in the assessment document. An acknowledgement form will be signed by the Program Specialist that states retraining has been performed and content of the needed information is understood. The Program Specialist will update Individual #2 and #3's assessments to include all of the required elements of a complete assessment within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants assessments to ensure that all of the elements of the assessments are completed, within 30 days of receipt of this plan of correction. [SW 11.18.15] |
10/14/2015
| Implemented |
| 2380.181(e)(13)(v) | Individual #2's assessment, dated 12/30/14, did not include progress and growth in recreation.
Individual #3's assessment, dated 10/7/14, did not include progress and growth in 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. | The Program Specialist will be retrained by the Site Director on the regulations specifically regulation 2380.181. This regulation specified the needed information that is to be present in each individuals assessment. An acknowledgement form will be signed by the Program Specialist stating that said information ahs been reviewed and understood. The Program Specialist will update Individual #2's assessment to include all of the required elements of a complete assessment within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants assessments to ensure that all of the elements of the assessments are completed, within 30 days of receipt of this plan of correction. [SW 11.18.15] |
10/14/2015
| Implemented |
| 2380.181(e)(13)(vi) | Individual #2's assessment, dated 12/30/14, did not include progress and growth in community integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | The Program Specialist will be retrained by the Site Director on the regulations specifically the regulation 2380.181. This regulation outlines the information that is needed for the assessment document. An acknowledgement form will be signed by the Program Specialist that states retraining has occurred and the content of the needed information for the Assessment is understood. The Program Specialist will update Individual #2's assessment to include all of the required elements of a complete assessment within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants assessments to ensure that all of the elements of the assessments are completed, within 30 days of receipt of this plan of correction. [SW 11.18.15] |
10/14/2015
| Implemented |
| 2380.183(4) | Individual #3 requires 1:1 supervision. The Individual Support Plan does not include a protocol to target the reduction of the 1:1 support. | 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 Program Specialist will work in conjunction with the said individuals Supports Coordinator to document the pertinent information needed to track achievement of a higher level of independence. This information will be added to said individuals I.S.P. The documentation will list the proposed achievement level and criteria to achieve a higher level of independence. Behavior tallies will be utilized to track progression on said goal. This information will be submitted monthly and reviewed quarterly with the Supports Coordinator and Program Specialist to determine the future level of independence required. |
10/14/2015
| Implemented |
| 2380.186(d) | Individual #1's Individual Support Plan(ISP) reviews, dated 1/14/15, 4/14/15, 7/14/15, were not sent to the Support Coordinator. Individual #2's ISP reviews, dated 11/30/14, 2/28/15, 5/28/15 and 8/28/15, were not sent to the Support Coordinator. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The Program Specialist will devise a chart that entails the due dates for each individuals Quarterly ISP review. This will accompany a check list that entails the individuals contact information as well as the Supports Coordinator contact information. The Program Specialist will initial the check list as well as file a copy of the acknowledgement letter along with report that is submitted to each individual and Supports Coordinator for record keeping purposes. The Program Specialist will submit all of the ISP reviews for Individual #1 and Individual #2 to the Support Coordinators within 30 days of receipt of this plan of correction. In addition, the Program Specialist will audit all of the participants records to ensure that all ISP reviews have been submitted to the Supports Coordinator and submit any review that have not been submitted as required, starting within 30 days of receipt of this plan of correction. |
11/02/2015
| Implemented |
| Article X.1007 | Peacful Living-Creative Gifts is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 was hired on 6/13/15. The criminal history check was requested on 6/16/15. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | THE Human Resources Department has revised their hiring processes. A check list document has been created and will be utilized to confirm that all necessary pre hire documentation has been completed in its entirety prior to on site employment. All potential employees will not be offered a position until all needed documents are present and filed in the employees Human Resources folder. The check off sheet will serve as a reassurance of needed documents and the date on which they were received. |
11/02/2015
| Implemented |