Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.59(b) | The accessible hot water from the water cooler, located just outside the bathrooms, measured 165 degrees Fahrenheit. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | Effective 2/9/22, a new water cooler was ordered and received which does not dispense any hot water. |
02/09/2022
| Implemented |
2380.82 | The entire doorway into the first aid room was blocked by a large wheelchair. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | Effective 2/2/22, during the inspection, the wheelchair was removed from blocking the entryway to the first aid room. |
02/02/2022
| Implemented |
2380.89(a) | The facility did not conduct a fire drill in June 2021. | An unannounced fire drill shall be held at least once a month. | At the time of inspection, the fire drill deemed missing was in the Extended Reach platform, but not printed out.
The fire drill was printed immediately for verification and is presented in the validation packet by citation number. |
02/02/2022
| Implemented |
2380.89(c) | The May 25, 2021, fire drill record did not include the time of evacuation of the fire drill. The field for this in the record stated, "9:50am."
The July 2, 2021, fire drill record did not include the time of evacuation of the fire drill. The field for this in the record stated, "45" but did not clarify seconds or minutes.
There are no records of the date the fire drill took place from August 2021-February 2022. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. | A fire drill was completed each and every month at PSI.
The corporate office was contacted to add a seconds section on the form in Extended Reach where the fire drills are recorded and saved.
The Date of Fire Drill section was added on 2/11/22 and a fire drill was performed.
The validation is provided in the attached documents by citation #. |
02/11/2022
| Implemented |
2380.89(g) | During the 2/2/22 onsite fire drill, staff did not evacuate Individual #3 to the designated meeting place. Staff walked with the individual directly passed the threshold to the building, then turned around and re-entered the building. Staff person #1 reported that they were allowed to only evacuate Individual #3 to one step outside the building due to the individual's ambulation needs. The facility could not provide a waiver for this regulation for Individual #3 or documentation from the Department stating Individual #3 did not have to evacuate to the meeting place for fire drills. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Effective starting with the March 2022 fire drill, all individuals will be walked to the end of the driveway to the designated meeting place. |
03/15/2022
| Implemented |
2380.113(c)(4) | Staff person #1's current, 7/21/21 physical examination record did not indicate if they were free from any medical problems that would inhibit their ability to perform their work duties. The field was left blank. | The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals. | Effective 2/3/22, each staff physical form will be submitted to the Director to verify that all needed information is completed on the form. Any incomplete forms will be returned to the employee to have a physician update and will be resubmitted to the Director.
The Director, once completed forms are correctly submitted, will copy the form into the proper compliance section in the Extended Reach program for that staff person to have on file. |
02/07/2022
| Implemented |
2380.171(b)(3) | Individual #2's record did not include the name, address, and telephone number of the person identified to be the individual's emergency medical consent person. Their record stated their emergency medical consent person was someone who is deceased. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | This citation was based on false information given by the county AE.
On 2/3/22, the Director verified with the respective provider, and also his mother, the listed contact is not deceased.
If this were the case, however, the Director would immediately update the information to include a current emergency consent person for the individual. |
02/03/2022
| Implemented |
2380.176(a) | Individual-specific record information stored in binders, was unlocked, accessible and unattended sitting in a basket, on the shelving unit by the kitchen. | Individual records shall be kept locked when they are unattended. | Effective 2/5/22, all individual records were placed in a locked cupboard in the program.
Staff was retrained on the importance of keeping all client records in a locked area within the program when not in use for confidentiality purposes. |
02/05/2022
| Implemented |
2380.181(a) | Individuals #1's and #2's assessments were not updated annually to include an assessment of their current needs and abilities over the previous 365 days. Their 2020 and 2021 assessments were verbatim. Additionally, Individuals #1's and #2's assessments didn't include all of their current medical diagnoses, an assessment of their lifetime medical history, their abilities to evacuate in the event of a fire, food and dietary needs, recommendations, medical information over the previous year, or accurate information based on their current needs and abilities at program. | 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. | Effective 3/21/22 the two assessments have been updated and items added that were missing.
All assessments for each individual being serviced in the program were reviewed for any missing information or information that may have been outdated.
Assessment procedures were reviewed with staff to eliminate this issue in the future. |
03/21/2022
| Implemented |
2380.21(u) | Individual's #1 and #2 did not have their regulatory right, defined in 2380.21(c), (d), (e), (f), (j), (k), (l), (m), (n), (o), (p), (r), and (t) explained to them on an annual basis. According to the annual review of rights documentation, the above rights were not included on this review with individuals. | 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. | On 2/8/22, updated individual rights papers were signed by individual #1 and individual #2.
The signed rights paperwork was uploaded into the Extended Reach platform for each individual to maintain records for compliance.
The Director verified that Individual Rights papers were on file for each individual being serviced in the program. |
02/08/2022
| Implemented |
2380.38(b)(1) | Staff person #2 started working with individuals on 8/25/21. They did not receive training in person centered planning until 9/10/21. There are no records maintained they received training in community integration, individual choice, and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | As of 2/5/22, the 24-hour shadowing documentation for PSI was changed to include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. |
02/05/2022
| Implemented |
2380.38(b)(2) | Staff person #2 started working with individuals on 8/25/21. There are no records maintained they received training in the prevention, detection, and reporting of abuse, suspected abuse, or alleged abuse in accordance with the Older Adults Protective Services Act, the Adult Protective Services Act, and applicable protective services regulations. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | As of 2/5/22, the orientation/24-hour shadowing documentation for PSI was changed to include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. |
02/05/2022
| Implemented |
2380.38(b)(5) | Staff person #2 started working with individuals on 8/25/21. There are no records maintained they received training in job-related knowledge and skills needed, outlined in individual-specific plans prior to working with individuals.
Staff persons #1, and #3-#7 have also worked directly with Individuals #1 and #2 over the previous year. At the time of the 1/31/2022 inspection, there are no records the above-mentioned staff were oriented to current, individual specific plans and protocols relating to the knowledge and skills staff need to properly provide treatment to individuals, until 2/3/22. Individual's #1 and #2 have individual support plans, assessments, and other protocols: GERD, aspiration precautions, seizure, fall precaution, food/puree diet precautions, behavior support plans, and SEEN plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | As of 2/5/22, documentation was printed to verify that Staff #2 was trained on all ISPs and signed off on various dates according to regulations. (Validation provided)
As of 2/5/22, documentation was printed out to verify that all staff read, understand, and sign off on new ISPs as they come into the program. (Validation provided) |
02/05/2022
| Implemented |
2380.39(c)(1) | There are no records maintained that Staff persons #1 and #8 received annual training in person-centered practice, community integration, individual choice, and supporting the individual to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Effective 2/16/22, training was held at PSI on person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.
Effective 2/16/22, the corporate office was made aware that the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships must be an annual training for compliance for PSI staff. |
02/16/2022
| Implemented |
2380.39(c)(2) | There are no records maintained that Staff persons #1 and #8 received annual training in the prevention, detection, and reporting of abuse, suspected abuse, or alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Services Act, the Adult Protective Services Act, and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Effective 2/16/22, the director conducted training for staff to include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations are required annual training for staff.
Effective 2/16/22, the corporate office (HR department) was made aware that the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations are required annual training for staff. |
02/16/2022
| Implemented |
2380.39(c)(3) | There are no records maintained that Staff person #1 received annual training in individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Effective 2/16/22, the director conducted training on individual rights to bring staff into compliance.
Effective 2/16/22, the corporate office (HR department) was made aware that individual rights is a required annual training for staff. |
02/16/2022
| Implemented |
2380.39(c)(4) | There are no records maintained that Staff person #8 received annual training in recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Effective 2/16/22, the director conducted a training on incident reporting to bring staff into compliance.
Effective 2/16/22, the corporate office (HR department) was made aware that incident reporting is required annual training for staff. |
02/16/2022
| Implemented |
2380.39(c)(6) | There are no records maintained that Staff person #1 received annual training in job-related knowledge and skills, outlined in each individual-specific plan of the individuals who they work with. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | As of 2/5/22, documentation was printed to verify that Staff #1 was trained on all ISP¿s and signed off on various dates according to regulations. (Validation provided)
As of 2/5/22, documentation was printed out to verify that all staff read, understand, and sign off on new ISPs as they come into the program. (Validation provided) |
02/05/2022
| Implemented |
2380.125(f) | Individual #2 takes psychotropic medications for psychiatric diagnoses. Their individual plan doesn't include a plan to address their social, emotional and environmental needs while attending the program. Staff person #1 confirmed this is accurate during the 1/31/22 inspection. | 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. | Effective 2/5/22, a SEEN plan was created for individual #2 due to the fact that this is a required document for any individual taking psychotropic medications for a psychiatric diagnosis.
The created plan was shared and read by all staff on 2/5/22. |
02/05/2022
| Implemented |
2380.126(a)(3) | According to Individual #1's current physical examination record, they have no known drug allergies, but do have seasonal allergies and contraindications to grapefruit and grapefruit juice due to some of the medications they take daily. Individual #1's May-November 2021 medication administration records (mars) only include their seasonal allergy. Individual #1's December 2021-February 2022 mars state they have allergies to Paxil and Risperdol, but this is not confirmed or recorded by a physician. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | Effective 2/2/22, all MARs in the program were reviewed for accuracy.
Effective 2/2/22, all MARs going forward will display the corrected allergy information due to a change on the original form in regards to allergies. |
02/02/2022
| Implemented |
2380.126(a)(6) | Individual #1's medication administration records (mars) from May 2021 to February 2022, do not include the dosage form of their Carbidopa-levo ER that was administered. According to the individual current physical examination and other medical and programming records at the facility, the individual's medications are to be crushed and administered in applesauce, yogurt, or pudding. The mars only state to, "administer one tablet by mouth 3 times a day."
Individual #2 requires their medication to be crushed and added to puree. The individual's June 2021 mar did not include this specific dosage form or order to crush the medication and add to puree prior to administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Effective 2/2/22, all MARs in the program were reviewed for accuracy.
The MAR for individuals #1 and #2 were corrected to add accurate dosing instructions. |
02/02/2022
| Implemented |
2380.129(a) | Staff person #5 was certified via the Department's initial medication administration training course on 1/3/2020. They weren't recertified via the annual medication administration training course until 3/1/21. The agency failed to complete additional medication administration reviews (mars) and medication observations with Staff person #5, due to their late re-certification, but allowed them to continue administering medications. Staff person #5 administered medication to Individual #1 today, 2/2/22, and wasn't certified, via annual medication administration training requirements, to do so.
Staff person #1 indicated they administer medications on occasion to individuals at the program. Staff person #1 had the required mars and medication observations completed for 2021, however did not have records that a practicum summary sheet was completed in 2021 or annual medication training and its requirements were completed in 2020. There are no records maintained that other forms of medication training allowed in 2020 were completed.
Staff person #3 also indicated they administer medication on occasion to individuals at the program. Staff person #3 had the required mars and medication observations completed for 2021, however, did not have record that a practicum summary sheet was completed in 2021 or annual medication administration training was completed in 2020. There are no records maintained that other forms of medication training allowed in 2020 were completed. | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration). | Effective 2/3/22, staff #5 completed the necessary reviews to be current with medication administration certification to pass medications in the program.
Effective 7/24/20, staff #3 had a completed summary sheet stored in Extended Reach management platform. (Submitted)
Effective 7/28/20, staff #1 had a completed summary sheet stored in Extended Reach management platform. (Submitted)
Due to Covid, PSI was closed from 11/15/2020 through 2/24/21. Both staff, #1 and #3, were recertified as trainers in February of 2021. Neither staff listed administered medication until their recertification was completed. |
02/07/2022
| Implemented |
2380.181(f) | According to the dissemination letter, Individual #1's current assessment was not sent to their current supports coordinator or their sisters who are a part of the individual plan team.
Individual #2's current assessment was not sent to their current supports coordinator or behavior support person. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Effective 2/10/22, copies of the current assessments were extended to all team members listed for both individuals by the Director. |
02/11/2022
| Implemented |
2380.182(c) | At the time of the 1/31/22 inspection, Individual #1's social, emotional, and environmental needs plan has not been updated since 2019. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Effective 2/8/22, the SEEN plan for individual #1 has been updated and all information has been added.
Effective 2/8/22, all staff have reviewed the updated version of the document. |
02/08/2022
| Implemented |
2380.186 | Individual #1's individual support plan (isp) states, "{Individual #1's} ISP team assessed the individual's needs and determined that {Individual #1} has a communication need because they are difficult to understand at times. Project able (the licensed facility) has a communication list of {Individual #1's} non-verbals on-site so that staff are able to review this and respond appropriately to {Individual #1} and encourage them to communicate verbally. This is not the same list as {Individual #1's} picture communication book as is available for staff reference, not {Individual #1's} use. Project able will also begin to remind {Individual #1} to slow down as the individual prefers this outcome to the communication/picture book. This method has been going well for the individual. Sometimes facial expressions given to {Individual #1} are enough to help remind them to slow their speech down." During the 2/2/22 onsite inspection, the facility stated there was no records that a picture book or another communication log/record was being used for Individual #1.
Individual #2's isp states they have many protocols and plans in their record for use in the program and staff are trained in all plans. The isp lists, blood pressure, diet, dental, diabetes, hypoglycemia, hyperglycemia, chocking risk, fall precautions, health promotions protocols. The facility was only able to provide seizure and diet protocols for Individual #2, and no documentation of staff training on said plans/protocols.
Individual #2's isp states the individual, "present with food stealing and PICA behaviors to include eating stones, band-aids and feces. {The individual} has pushed over other consumer and pushed past staff in attempts to steal food. Project Able staff have been trained on PICA and have also had behavior support plan trainings to work with {Individual #2}." The facility could not provide staff trainings or a behavior support plan. | The facility shall implement the individual plan, including revisions. | On 2/7/22 PSI confirmed that the program for individual #1 does not now, nor has had in the past year or more, a picture book in the residential program for this individual to use.
On 2/7/22 PSI developed a list of words for individual #1 that staff may have difficulty understanding, especially newer staff, when this individual is trying to communicate about certain topics. Staff have been trained on the words and have signed off indicating an understanding of communication needs.
Effective 2/7/22 all protocols from the home were put in place in the day program. All Staff has read the information and signed off for completion and understanding. |
02/07/2022
| Implemented |