| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.83(b)-1 | The fire alarm was not checked during December 2015. | An employe trained in the operation of the equipment shall check the fire alarm monthly. | The staff assigned to perform the monthly checks was on vacation in the month of December. The facility has assigned a back up staff person, Director of Business Services Allentown, who will monitor for compliance and also conduct the monthly fire alarm checks and other monthly safety responsibilities in the absence of the primary assigned staff. |
10/10/2016
| Implemented |
| 2390.84(g) | In the program area, fire extinguisher 32 is not fully charged. | Fire extinguishers shall be inspected and approved annually by the local fire department or other fire safety authority. The date of the inspection shall be on the extinguisher. | The fire extinguisher was checked on 6/29/16 as part of the routine monthly safety inspection. After being notified about the fire extinguisher during the site visit, Kessler- O¿Brien, the suppliers of the equipment were called to inspect it. Their tech determined that the extinguisher had developed a slow leak and it was replaced. Monthly checks of the equipment will be continued. |
10/10/2016
| Implemented |
| 2390.111(b) | Individual 2 was interviewed for the program on 8/18/2015 but did not receive notification in writing of his acceptance into the program. Individual 2s date of admission to the program was on 11/20/2015. | Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. | The MH/ID Compliance Monitor retrained on the Program Specialists (Job title Case Manager) on 10/10/16 regarding the requirement to send an applicant a written notification of acceptance within 30 days of referral/intake meeting and that this must be maintained in the file. They have been provided with a template for the letter and a checklist for new clients to insure compliance. |
10/11/2016
| Implemented |
| 2390.112(a)-2 | There is not a date of orientation written in the records of individuals 2 and 3. | The date of the orientation shall be written in the client's record. | The MH/ID Compliance Monitor instructed the program specialists on 10/10/16 to enter a case note on the individual¿s first day, documenting the orientation. Program Specialists will also have an orientation checklist to ensure full compliance. |
10/10/2016
| Implemented |
| 2390.124(5) | There is not a physical examination in the record of individuals 1, 2, 3, and 4. | Each client's record must include the following information: Physical examinations. | MH/ID Compliance Monitor reviewed the requirement with the Program Specialists on 10/10/16. Staff are currently contacting SC to obtain copies of physical examinations for the four individuals and are checking each client file to determine if more are missing. A physical will be requested as part of intake for each new client. |
10/10/2016
| Implemented |
| 2390.124(8)(ii) | Individual 4s record does not contain a copy of the ISP invitation for 2015. | Each client's record must include the following information: A copy of the invitation to: The annual update meeting. | The MH/ID Compliance Monitor retrained the Program Specialists (Job title Case Manager) on 10/10/16 regarding the requirement of an ISP invitation being maintained in the file. Should an invitation not be forthcoming from the SC, the Program Specialist will verify in writing the date/time of the meeting as scheduled, requesting confirmation from the SC with a copy of the invitation. |
10/10/2016
| Implemented |
| 2390.124(9)(ii) | Individual 1s records does not contain a copy of the ISP signature sheet from the meeting held on 4/19/2016. | Each client's record must include the following information: A copy of the signature sheet for: The annual update meeting. | The MH/ID Compliance Monitor retrained the program specialists on 10/10/16 regarding the requirement. Program Specialists will make copies of the signature sheet prior to the end of the ISP meeting, rather than wait for the SC to send it, or have to request it later. |
10/10/2016
| Implemented |
| 2390.151(a) | Not all of the individuals are receiving assessments as regulated. Individual 3 was admitted to the program on 11/30/2015 and received his intial assessmen on 2/25/2016. Indivdiual 1s last assessment was completed on 2/27/2015. | Each client 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. | The program specialist mistakenly believed the initial assessment was due sixty attendance days; and individual #3 had an extremely limited attendance schedule. The MH/ID Compliance Monitor has retrained both program specialists that the initial assessment must be completed with in 60 calendar days. Supporting documentation will be provided with the next new admission. Individual #1 assessment was done late, because it was originally missed when the long term Program Specialist left and the new Program Specialist came on board. Staff have been retrained in the need for timely annual assessments by the MH/ID Compliance Monitor. Program Specialist Jasmin Rodriguez has created a tracking calendar for all client documents as of 8/15/16. |
10/20/2016
| Implemented |
| 2390.152(d)(1) | Individual 1 was admitted to the program on 10/2/2006. The CEO/staff 3 stated that individual 1 did not have an ISP meeting and is not receiving Federal or State funding for her placement. Individual 1 does not have an ISP. | The plan lead shall develop, update and revise the ISP according to the following: The ISP shall be initially developed, updated annually and revised based upon the client's current assessment as required under § § 2380.181, 2390.151, 6400.181 and 6500.151 (relating to assessment). | Individual 1 is privately funded as per her advocate¿s and her own choice. Goodwill does not have access to the ISP for individual I through HCSIS since we are not an ISP authorized provider. In this instance the SC did not immediately provide a copy of the ISP, but has provided one upon request. Goodwill does attend the ISP meetings for Individual I when made aware of the schedule. Goodwill cannot create an ISP for her as this would be a violation of 2390.152(d)(1) which states that there can be only one ISP for all licensed services. In addition, 2390.152 (b) states that if the individual has an SCO, which is the case for Individual 1, then 2390.152 (d) does not apply.
(--Goodwill has requested and received a copy of Individual #1's ISP from the Supports Coordinator. Goodwill will continue to request the ISP from the Supports Coordinator. - CH 10/12/2016 via telephone with Cheryl Garr.) |
10/11/2016
| Implemented |