| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(e) | Fire drills conducted during the months of April 2018 through April 2019 all utilized the front door as the exit route. | Alternate exit routes shall be used during fire drills. | All Crosswalk staff will be retrained in the licensing requirements to maintain compliance with Chapter 55 PA Code 2380.89(e) by 7/31/19. Additionally, the Program Specialist has developed a chart to list the exit to be used during each monthly drill to ensure that alternate exits are being used regularly. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance |
07/31/2019
| Implemented |
| 2380.111(c)(10) | The annual physical examination dated 6/15/18 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of emergency.
The annual physical examination dated 5/07/18 for Individual #2 did not include medical information pertinent to diagnosis and treatment in case of emergency.
The annual physical examination dated 5/03/19 for Individual #3 did not include medical information pertinent to diagnosis and treatment in case of emergency.
The annual physical examination dated 3/27/19 for Individual #4 did not include medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical form for Individual # 1 dated 6/15/18, for Individual # 2 dated 5/7/18, for Individual # 3 dated 5/3/19 and for Individual # 4 dated 3/27/19 will be updated to include the following information: medical information pertinent to diagnosis and treatment in case of emergency by 7/31/19. In the future, the agency Nurse will be responsible to ensure that all physicals for participants that are residents of Dayspring Homes are completed on the appropriate physical form which includes a section for Medical information pertinent to diagnosis and treatment in case of an emergency. The agency Nurse will also be responsible for reviewing all physical forms for participants who live with other providers or with family to ensure that all required information is on the form. The agency Nurse and Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance |
07/31/2019
| Implemented |
| 2380.181(e)(13)(i) | The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days 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 Annual Assessment for Individual # 3 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 3 will be updated to include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. |
07/31/2019
| Implemented |
| 2380.181(e)(13)(ii) | The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of motor and communication skills.
The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days 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 Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to 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 Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. |
07/31/2019
| Implemented |
| 2380.181(e)(13)(iii) | The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of personal adjustment..
The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of personal adhustment. | 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 Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: progress over the last 365 days in the area of personal adjustment. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. |
07/31/2019
| Implemented |
| 2380.181(e)(13)(iv) | The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of socialization.
The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of socialization. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: progress over the last 365 days in the area of socialization. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. |
07/31/2019
| Implemented |
| 2380.181(e)(13)(v) | The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of recreation.
The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. The
Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. |
07/31/2019
| Implemented |
| 2380.181(e)(13)(vi) | The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of community integration.
The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community integration. | The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: progress over the last 365 days in the area of community integration. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. |
07/31/2019
| Implemented |
| 2380.181(f) | The assessment dated 1/02/19 for Individual #1 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting.
The assessment dated 9/11/18 for Individual #2 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting.
The assessment dated 10/11/18 for Individual #3 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting.
The assessment dated 12/20/18 for Individual #4 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting. | 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). | Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380.181 (f) by 7/31/19. Additionally, the Annual Assessment for has been updated to include the following statement ¿This assessment was shared with the team at least one month prior to the ISP meeting and documentation of how that was shared is attached: YES / NO¿. This statement will serve as a prompt to the manager completing the assessment to ensure this requirement is met. As part of the training that management staff will receive, they will be educated in practices to be used to ensure that the assessment is completed within the correct timeframe and what methods should be used to share the assessment with the team as well as what type of documentation is needed to show that it was shared. The practices to be used will include completing the Annual Assessment at the time of the third quarterly ISP review to ensure that there is adequate time to complete it properly and to share it with the team. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance.
((The date the assessment was sent to the team will be kept -CH 7/18/19)) |
07/31/2019
| Implemented |