| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.32(b)(3) | According to Individual #1's current, 10/3/19 physical examination record, he is prescribed Klonopin as needed for anxiety. The individual displays symptoms of anxiety when in attendance to the facility and out in the community with staff. Described in 2380.125(f) of this report, the agency failed to address this medication and implement a proper plan to have the medication available and administered to the individual should he require it when displaying symptoms of anxiety at the facility or in the community with staff. This medication was listed in his record since 10/3/19, on his current physical examination record.
Individual #3 is administering her insulin injections independently while in attendance of the facility. However, the individual's current, 8/31/2020 agency assessment states she can not self-administer medications and does not know the dosage of insulin she has to administer daily. The agency does not have staff available to administer insulin to Individual #3 nor are they aware of the individual's insulin regimen to ensure she is administering the correct dosage daily.
Additionally, Individual #3's current, 1/17/2020 physical examination record states she is prescribed Glucagon 3mg/actuation medication as needed for one application, once for severe hypoglycemia reaction. During the 10/1/2020 inspection, Staff person #2 reported to licensing staff that the agency is not aware if Individual #3 brings the medication with her to program, keeps the medication at program, is able to administer the medication if needed, nor are agency staff trained in how to administer the medication should the individual require it. The agency does not have a plan in place to ensure the individual can quickly obtain this medication should she have a severe hypoglycemia reaction while at the facility. | The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Safety and protection of individuals. | SEEN plan procedures/ regulations have been reviewed with Program Specialist and the following format for creating SEEN plans will be followed.
Update SEEN Plans
a. Plans to Include:
i. Medication Name/dosage/administration
ii. Why medication is needed.
1. Diagnosis
2. Symptoms we might see
iii. Plan of Support
1. What will we do?
2. How can staff assist this individual
3. Who will we contact to get meds or additional support as needed
iv. List that plan has been reviewed with the individual/family/team
1. Provided a copy to SC to place in the ISP
2. Provide Copy to Family, Individual, or whoever else necessary.
Individual #3 has been placed on a temporary hold until adult Enrichment can complete the following:
Medication Administration Course
Certified Diabetes Training
As part of the individuals return to program, a plan will be put in place for administration of Emergency Diabetic medication. This will include how the medication is made accessible to the individual, plan for administration, such as contacting EMS, and when administration of emergency medication is necessary. |
11/13/2020
| Implemented |
| 2380.53(a) | Individual #1's current, 9/14/2020 individual plan states that he will and has confused poisonous materials in the past, especially if they look like a drinking item. Throughout the facility, poisonous materials were found unlocked and accessible to individuals in attendance. There were approximately 5 large bottles of poisonous materials that contained a label to contact poison control center if ingested, in all four program rooms of the facility and the bathrooms. Some of those items were Clorox wipes, hand sanitizer, Zep cleaning solution, and aerosol spray cleaners. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | All materials determined to be poisonous will be kept in a locked closet or cabinet at all times when not in use. This will be done to ensure the health and safety of all individuals deemed unable/unsafe to be around these types of materials. |
11/13/2020
| Implemented |
| 2380.55(b) | Thirteen insect carcasses (appeared to be various flies, wasp, bee, and Spotted Lanternfly) were present inside the facility during the 10/01/20 inspection. | There may not be evidence of infestation of insects or rodents in the facility. | Currently we have an existing contract with pest control agency, Tomlinson and Bomberger. They inspect and treat quarterly. Additionally we will be replacing our cleaning company for more adequate cleaning service which will help ensure cleanliness of facility. Completed by 12/1/2020 |
12/01/2020
| Implemented |
| 2380.59(b) | The temperature of the water coming from the drinking dispenser outside the kitchen, measured 179 degrees Fahrenheit. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | Hot water option will be disabled on water cooler through the use of a switch on the rear of the machine and the disconnecting of the hot water line if applicable. Completed 10/1/2020. Additional action included contacting water cooler servicing agency to permanently disconnect hot water from cooler. Call was placed on 10/28/2020 and service was completed on 10/29/2020. |
10/29/2020
| Implemented |
| 2380.69(e) | The bathroom in the rear program area, closest to the staff offices, was not equipped with soap to wash one's hands after utilizing the bathroom. The sink in the bathroom was also taped off with blue tape in the shape of an X over the sink, for one to not use the sink after using the restroom. Licensing representative witnessed an individual using said bathroom during the 10/1/2020 onsite inspection, and not have soap or sink to use to wash their hands.
Another sink in the front program room, was taped off with blue tape with an X so individuals did not have a sink to use after using the restroom. | Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer. | Restroom issues were related to covid-19 procedures that were initially developed as part of our re-opening plan. However, all restrooms, including sinks have been re-opened and include needed supplies, including soap. Corrected 10/2/2020 |
10/02/2020
| Implemented |
| 2380.82 | A trashcan, approximately 2 and ½ feet high, was placed in front of a bathroom door in the rear, program room. Staff indicated it was a staff only bathroom so the trashcan was placed there so individuals could not move the trashcan or use the bathroom. However, it is a bathroom within the licensed program space and for individual's use as well. The door to the bathroom was being blocked by a trashcan.
The gate latch on the outdoor, rear, metal fenced in area, was approximately 4 and 1/5 feet off the ground, preventing the individuals who attend program and utilize wheelchairs, from opening the latch and maneuvering through the gate. Per program manager, Staff person #2, some individuals' wheelchairs are wider than the opening of the metal gate and cannot maneuver through the gate at all, completely obstructing their egress from the outdoor, fenced area. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | Trash can has been removed and restroom was made accessible to all participants. This was a secondary restroom and was closed as part of COVID-19 re-opening plan. Corrected 10/1/2020
Gate latch has been removed entirely. There is a top bracket that prevents the gate from swinging inward in case of emergencies. Gate is accessible for all participants and staff. Wheel chair widths and gate opening were measured. All individuals can pass through gate opening as opening exceeds ADA requirements. Gate opening measure 36 inches wide. Corrected 11/1/2020. |
11/01/2020
| Implemented |
| 2380.91(a) | Individual #1 received training on general fire safety and the requirements defined in 2380.91(a) on 1/25/19 and not again until 9/30/2020. He returned to the facility on 9/11/2020 after the pandemic closure that occurred on 3/16/2020 but did not receive the required fire safety training until 19 days after returning to the program. | 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. | Annual fire training dates will be added to Program Specialist participant tracker. Fire safety training will be completed annually in addition to Monthly Fire drill/training to ensure training is completed on an annual or more frequent basis. |
11/20/2020
| Implemented |
| 2380.111(c)(3) | REPEAT from 6/5/19 annual inspection: Individual #3's 1/17/2020 physical examination record states that the DPT (Diphtheria/Tetanus) immunization was completed 10/30/2008. The CDC recommends "1 dose Tdap, then TD or Tdap booster every 10 years"; the immunization booster should have been administered by 10/30/2018. There is no evidence that Individual #3 has received a Diphtheria/Tetanus immunization every 10 years and she is attending the program. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #3 is currently on hold due to medication administration issues. However, individual will be requested to have DPT completed prior to return. 1/1/2021 Moving forward, Immunization due dates will be added to Program Specialist Participant Tracker form to ensure future time frames are met. 11/20/2020
Retrain Program Specialist in current policy around late TB tests and update policy to include required immunizations. Current policy states that anyone with a late or missing TB will be placed on hold until it has been completed and documentation has been provided to the Program Specialist. This will now also include Immunizations such as DPT. Review physicals immediately upon receipt to ensure accuracy and to verify that all areas with due dates meet requirements, ie. Tb, immunizations and physical completion date. |
11/20/2020
| Implemented |
| 2380.111(c)(5) | REPEAT from 6/5/19 annual inspection: Individual #2's current, 7/17/2020 physical examination record states that his previous Tuberculin skin test was read with negative results on 08/03/18 and the most recent Tuberculin test wasn't completed again until 8/21/20, outside of the 2-year testing requirement. Individual #2 returned to the program on 7/13/20. | 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. | Retrain in current policy around late TB tests and newly included specifics on Immunizations. Current policy states that anyone with a late or missing TB will be placed on hold until it has been completed and documentation has been provided to the Program Specialist. Review physicals immediately upon receipt to ensure accuracy and to verify that all areas with due dates meet requirements, ie. Tb, immunization and physical completion date |
11/11/2020
| Implemented |
| 2380.111(c)(6) | Individual #1's 10/3/19 physical examination records do not include if he is free of communicable diseases. The field was left blank on the physical examination record. | 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. | Program Specialist will review/re train on areas needed to be completed as part of the annual physical. Upon receipt of the physical, Program Specialists will review for accuracy and to verify all areas are completed. Specific areas to be reviewed include Communicable Diseases. |
11/11/2020
| Implemented |
| 2380.111(c)(9) | Individual #1's 10/3/19 physical examination records did not include a full list of his allergies and contraindicated medications/sensitivities. His 2019 physical examination record stated he has a histamine reaction to narcotics and an allergy to versed medication. However, his current allergies of seasonal allergies and gluten sensitivities documented on his 2018 physical examination record was not included on his 2019 physical examination record. Additionally, his current 9/14/2020 individual plan also states he has a lactose sensitivity and should avoid foods containing this. | The physical examination shall include: Allergies or contraindicated medication. | Program Specialist will review/re train on areas needed to be completed as part of the annual physical. Upon receipt of the physical, Program Specialists will review for accuracy and to verify all areas are completed. Applicable areas such as allergies will be compared against the most current ISP and any discrepancies found will be rectified through the appropriate contact including current physician, family, residential provider and SC. |
11/11/2020
| Implemented |
| 2380.111(c)(11) | Individual #1's 10/3/2019 physical examination record did not include dietary information. The physical examination record stated dietary information was not applicable. However, according to his current, 9/14/2020 individual plan, created by the individual and his team members, it states he has a gluten and lactose sensitivity and should avoid foods containing these items. His individual plan also states that he follows a renal diet, which is low in sodium to help with his diagnosed electrolyte imbalance, renal disease and metabolic acidosis due to having one kidney, Chronic Kidney disease, 3 kidney transplants, and a history of renal failure. His current, 9/14/2020 individual support plan states he needs his food cut up and put on his plate one at a time and this isn't listed on his physical examination record. | The physical examination shall include: Special instructions for an individual's diet. | Program Specialist will review/re train on areas needed to be completed as part of the annual physical. Upon receipt of the physical, Program Specialists will review for accuracy and to verify all areas are completed. Applicable areas such as dietary information will be compared against the most current ISP and any discrepancies found will be rectified through the appropriate contact including current physician, family, residential provider and SC. |
11/11/2020
| Implemented |
| 2380.173(1)(v) | At the time of the 10/1/2020 annual inspection, Individual #1's photograph in his record was last updated in January 2019, and not on an annual basis. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | Current photos will be taken of each individual yearly and dated using Month, Day and Year. This current photo will be placed in the individual file. This will be completed for all current participants by 12/1/2020. New participants will have their picture taken as part of the enrollment process and annually or more frequently as needed thereafter. |
12/01/2020
| Implemented |
| 2380.181(e)(4) | Individual #1's current, 3/27/2020 assessment does not define when he can be within earshot supervision of staff. His assessment states he receives line of sight supervision while in the facility and when on an outing with agency staff, he is allowed "up to 15 minutes of alone time for staff to use the restroom, participate in volunteering opportunities, and there will also be times when {the individual} is within earshot but not line of sight. After these 15 minutes, staff can do a visual check."
His current, 9/14/2020 individual support plan states that he also has a tendency to shove items up his nose and may need monitored due to this. His supervision needs, in regard to the monitoring needed to prevent him from putting an item up his nose, is not assessed in his 3/27/2020 assessment. | The assessment must include the following information: The individual¿s need for supervision. | Team meetings, conducted in person, virtually or over e-mail will continue to be held when requesting a change to an individual¿s supervision needs. Meeting will include review of potential safety concerns and individual support needs to determine if requested change is appropriate. ISP will be reviewed by team, and requests will be made by the Program Specialist to have needed areas of the ISP updated to reflect change in supervision. Changes will also be reflected in the individual¿s assessment. 12/1/2020 |
12/01/2020
| Implemented |
| 2380.181(e)(5) | Individual #3's current, 8/31/2020 assessment does not include her ability to administer medications. Her assessment states that she cannot self-medicate, as section 2380.181e5, states "Does this individual self-administer medications -- No". Her assessment also states that she "calls one of [Individual #3's] parents before lunch to get the proper dosage of insulin [Individual #3] will need. [Individual #3] then administers [Individual #3's] insulin independently." These sentences are contradictory and do not define her ability to administer medications.
According to Individual #3's 1/17/2020 physical examination record, she is prescribed Glucagon 3mg/actuation medication as needed for severe hypoglycemia reaction. The individual's assessment does not include her ability to administer this medication. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Assessment will be updated to reflect accurate representation of individual #3¿s ability to self-administer medications and will include a plan for access to and administration of emergency medications. Completed by 1/1/2021
Adult Enrichment will be undergoing Medication Certification and will ensure assessments accurately reflect information regarding med administration should it apply to the individual. |
01/01/2021
| Implemented |
| 2380.181(e)(6) | Individual #1's current, 3/27/2020 assessment did not include his ability to use and/or avoid poisonous materials. His assessment stated, "generally {the individual} does not bother with hazardous substances. At adult enrichment all hazardous substances are kept secure in a locked closet or cabinet." A general statement does not assess the individual's specific ability to use and/or avoid poisonous materials. The individual's individual support plan states that he has confused poisonous substances in the past, especially if they resemble a drink. Poisonous materials were found unlocked and accessible at the program during the 10/1/2020 inspection. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Team meetings, conducted in person, virtually or over e-mail will be held when assessing an individual¿s ability to identify, use, avoid and be in the presence of poisonous materials. Based on this determination, Adult Enrichment will take the necessary precautions to ensure poisonous materials are kept away from the individual in a secure and locked location when not in use. Assessment and ISP will be updated to accurately reflect an individual¿s ability to identify, use, avoid and be in the presence of poisonous materials. 11/23/2020 |
11/23/2020
| Implemented |
| 2380.181(e)(10) | Individual #1's current, 3/27/2020 assessment does not include his lifetime medical history information that is updated on an annual basis. At the time of the 10/1/2020 inspection, the most current information included in his assessment regarding his lifetime medical history, was last updated in 2016. The individual has three known allergies to Narcotics, Versed, and seasonal allergies that are not included in his lifetime medical history document, nor is his as needed medication for Anxiety. | The assessment must include the following information: A lifetime medical history. | Annual Assessments will include a review of lifetime medical history to be updated as needed or annually as required. Updates will be provided to the individual and the individuals support team. Medical history will include pertinent change to health and medical status. Change in lifetime medical history will be added to the assessment as it is received. If no additions or changes are needed to an individual¿s Assessment as art of the annual review, this will also be noted. 11/23/2020 |
11/23/2020
| Implemented |
| 2380.181(e)(12) | Individual #1's current, 3/27/2020 assessment did not include recommendations. It stated, "he currently attends day program two days per week where he is part of the production team and earns a paycheck. At this time, he has not expressed interest in seeking out further vocational programming. There are no recommendations at this time." | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Quarterly progress reports, interviews, observations, and the individuals personal interests/needs will be used to identify recommendations to further the individuals success both in and out of the program. Recommendations will be added to the annual assessment as applicable. 11/13/2020 |
11/13/2020
| Implemented |
| 2380.21(u) | There is no evidence that the facility reviewed the individuals' rights and the process to report a rights violation to Individual #1 upon admission on 1/25/19 or annually thereafter.
The Department issued updated, regulatory individual's rights effective immediately on 2/3/2020. There is no evidence that Individuals #1-#3 had their updated, regulatory rights and the process to report a rights violation reviewed with them. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | Individual rights will be initially reviewed at the time of enrollment for new participants. Individual rights for current participants will be reviewed no later than December 1st and then annually on their enrollment anniversary date or more frequently as needed. Individuals/legal guardians will sign off that these rights have been reviewed. A copy of this record will be placed in the individual file and also provided to the individual/legal guardian.
Individuals who have not returned to program due to COVID-19 will have these rights reviewed prior to or on the day of their return to program. |
12/01/2020
| Implemented |
| 2380.36(a) | Staff person #1 did not receive training in notification of the local fire department as soon as possible after a fire is discovered prior to working with individuals in September 2019.
At the time of the 10/1/2020 inspection, Staff person #3 received training in the general fire safety requirements defined under 2380.36(a), except for notification of the local fire department as soon as possible after a fire is discovered, on 4/10/19 and not again since then. There is no evidence that he received training in notification of the local fire department as soon as possible after a fire is discovered in 2019 or 2020, outside the annual time frame requirement. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | Currently staff participate in Monthly fire drills which also provides training on evacuation procedures, primary/secondary exits, staff responsibilities, fire extinguishers, primary/secondary meeting places. Training will be updated to include specific information on contacting the local fire department. |
12/01/2020
| Implemented |
| 2380.39(a)(2) | The agency's identified training year to complete their required training hours is the calendar year, January to December. Staff person #3 only received 10 hours of training for the 2019 calendar year. Outside of the 8 hours he was credited for a full day of training on 11/25/19, he only received an additional 2 hours of training on 2/27/19 and 4/10/19, for a combined total of 10 hours of training. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct supervisors of direct service workers. | All staff will be re trained in the annual training requirements. Training will include available training options, amount of hours that can be completed in any working day and how many training hours are needed for the training year. Training completed 11/4/2020. |
11/04/2020
| Implemented |
| 2380.121(e)(2) | Individual #3 is administering her own insulin while at program. However, per her current, 08/31/20 agency assessment, Individual #3 "calls one of [Individual #3's] parents before lunch to get the proper dosage of insulin [Individual #3] will need. [Individual #3] then administers [Individual #3's] insulin independently." Her 08/31/20 assessment also indicates that Individual #3 cannot self-medicate, as section 2380.181e5, states "Does this individual self-administer medications -- No". For this insulin administration, Individual #3 does not know how much insulin is to be administered daily and relies on her parent's instruction via telephone call, to inform her of the amount of insulin to inject daily. | To be considered able to self-administer medications, an individual shall do all of the following: Know how much medication is to be taken. | Individual #3 is currently on hold until Adult Enrichment can select and train staff in Medication Administration as well as complete annual Certified Diabetic training. The expected completion for this is 1/1/2021.
Assessment will be updated to include corrected med administration information moving forward. |
01/01/2021
| Implemented |
| 2380.125(f) | Individual #1's current, 9/14/2020 individual plan does not include his psychiatric medications (Klonipin), their dosages, reason for prescribing the meds, and a protocol to address the social, emotional and environmental needs of the individual related to the symptoms of his diagnosed psychiatric illness for which he is prescribed the medication. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | SEEN plan will be updated to include dosage, reason for prescribed medication, signs/symptoms, plan to support the individual, how medication will be administered if needed, and contacts that would need to be made. Plan will be updated as needed.
Update SEEN Plan
a. Plans to Include:
i. Medication Name/dosage/administration
ii. Why medication is needed.
1. Diagnosis
2. Symptoms we might see
iii. Plan of Support
1. What will we do?
2. How can staff assist this individual
3. Who will we contact to get meds
iv. List that plan has been reviewed with the individual/family/team
1. Provided a copy to SC to place in the ISP
2. Provide Copy to Family, Individual, or whoever else necessary. |
11/13/2020
| Implemented |
| 2380.181(f) | There is no evidence that Individual #2's and #3's 6/24/2020 assessments were sent or given to the individuals themselves. The individuals' records states that the assessment was placed in the individual's file at the facility. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Moving forward Assessments will identify that a copy of the current annual assessment has been provided to the individual. Assessments will include method of delivery and date of completion. 11/13/2020 |
11/13/2020
| Implemented |