Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00113633 Renewal 06/29/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Two bottles of eye wash and many packets of antiseptic cleaning solutions that contained the label to "contact poison control center if ingested" were found unlocked and accessible in the first aid kit hanging on the wall of the first aid room. Five containers of deoderant and a white, lotion-like substance was unlocked and accessible in the 1:1 room activities filing cabinet. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The deodorant and lotion bottles had been used in Site II as part of a packaging task, and the containers had been sealed shut with glue. In the process of the closing of Site II and moving all needed items to Site I, some of these had been transferred as well, although they were no longer being used. In the time between the move in January and the inspection, the glue apparently dried out, allowing the bottle to be open. The Program specialist has disposed of all of these items. The Program Specialist checked throughout the various cabinets and no other toxic items were found. The Program Specialist reviewed the items in the first aid cabinet for toxicity, the eye wash and antiseptic were the only items so identified. The eye wash and antiseptic were removed from the first aid kit and put in the locked cabinet in the first aid room. The Program Specialist has retrained staff on the need to keep poisons securely locked; and signs have been posted in the storage areas as a reminder. 07/21/2017 Implemented
2380.84The facility had a fire saftey inspection completed on 4/14/16 and none since then. The agency did not attempt to reach out to an inspector to have the building inspected until 6/21/17, passed the annual due date. The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The fire safety inspection was conducted on 7/13/17. Although the written report will not be received for a few weeks, the only recommendations were to replace batteries in two of the emergency lights in the building, and this has been completed as of 7/18/17. The program itself is closing as of 12/31/17, so no further action is necessary regarding future inspection dates. 07/18/2017 Implemented
2380.111(c)(6)Individual #1's 12/12/16 physical examination form did not indicate if he/she was free of communicable diseases. The field was left blank. 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.The MH/ID Compliance Monitor has reviewed the requirement with the Program Specialist. The "free of communicable diseases statement" (Y/N) was not answered, but the section did not indicate any need for precautions as stated, allowing a presumption of inapplicable under the regulations. Previous physicals and other records always have indicated that the individual did not have any communicable disease. The Program Specialist contacted the residential provider on July 3, 2017 to confirm it. The Program Specialist is checking all files to ensure all pertinent information is present, including the communicable disease statement. 07/21/2017 Implemented
2380.173(7)Individual #1's current Individual Support Plan (ISP) was not kept in his/her record. The ISP in his/her record was last updated over a year ago on 6/17/16. There have been 8 updates to his/her ISP since then, including a critical revision to reflect the transfer of Individual #1 from a different program to this program. Each individual¿s record must include the following information:  A copy of the current ISP.Since there are no notifications from the HCSIS system regarding updates to the ISP; the Program Specialist will routinely check HCSIS for all updates the first week of the month, and print and file the newly created critical revisions. This will guarantee the Program Specialist has the most up to date ISP in the individual¿s file. The Program Specialist has reviewed all files and ensured the most recent ISP has been filed. The most recent ISP for Individual #1 is now in the file. 07/17/2017 Implemented
2380.181(e)(10)Individual #1's 4/7/17 assessment did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.Since the 2380¿s require a lifetime medical history as both part of the assessment and as part of the physical, we were advised in past years to include two copies of the history, one with each document, in the same file. Individual 1¿s file did have two copies of the history, however, both were in the same section of the file with the physical exam. The MH/ID Compliance Monitor has retrained the Program Specialist to staple one copy with the physical and staple one copy with the Assessment to insure that it is included with both. The Program Specialist is reviewing all files for compliance. 07/21/2017 Implemented
2380.186(a)Individual #1's Individual Support Plan (ISP) reviews are late. His/Her 2/22/17 ISP review reviewed material from November 2016-January 2017. His/Her 5/9/17 ISP review covered the 3 month time frame from February 2017-April 2017. A review should have been completed on 2/4/17 then another review on 6/4/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.The program specialist reviewed the file with the Compliance Monitor and discovered the error in dates has been ongoing for at least the last two years. It appears a quarterly had been delayed due to Individual 1¿s absence for an extended period and written to match the date of the review meeting, but then the three month reviews were mistakenly scheduled in relation to that delayed date, rather than moved up to coincide with the ISP again. A review should have been completed on 2/4/17, and 5/4/17 (not 6/4/17 which would be four months). The next one is currently scheduled for 8/1/17 and this will bring the reviews into the correct cycle once again. Program Specialist now has a form for the file that allows her to track the due dates in relation to the ISP and will use it with all files. The correction date reflects the date the August review meeting will be held and the written review finalized. 08/01/2017 Implemented
2380.186(c)(1)Individual #1's Individual Support Plan (ISP) reviews did not review his/her participation and progress during the prior three months towards his/her socialization outcome. The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.The Program Specialist is writing an addendum to the 5/9/17 review discussing program toward the socialization outcome. The MH/ID Compliance Monitor has retrained the Program Specialist to review the specific ISP document outcomes prior to writing the quarterly review to ensure all areas pertinent to Goodwill are addressed. The ISP quarterly review form has been revised by the Compliance Monitor to more explicitly direct that all pertinent ISP outcomes are to be addressed. The Program Specialist is reviewing all files for compliance. 07/21/2017 Implemented
2380.186(c)(2)REPEAT violation from 6/29/16 renewal inspection: Individual #1's 5/9/17 Individual Support Plan (ISP) review did not include a review of his/her behavior support plan, if the plan was utilized, and 1:1 staffing needs for the previous three months. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.While the review included behaviors identified in the SEEN plan; it did not address when /if and how the plan was utilized during episodes and its effectiveness. Nor was the need for 1:1 support reviewed on the quarterly. The MH/ID Compliance Monitor has trained the Program Specialist on the required information, and the Program Specialist is writing an addendum to the quarterly to include the specifics. The Program Specialist is reviewing all files for compliance. The Program Specialist is revising the daily activities tracking form to all for tracking the individual incidents and the effectiveness of the plan. 07/21/2017 Implemented
Article X.1007Goodwill Industries 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 3/31/17; the criminal history check was requested on 4/3/17.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.Site I is the only Goodwill program licensed as an Older Adult Day Program under the Department of Aging and as an Adult Training Facility under Office of Developmental Programs. Under ODP, the criminal history check is required within five days of start. Under DOA, the criminal history check is required prior to hire date. In this instance, the Manager of the program site followed the 2380 regulations for ODP, but failed to consider the requirements under DOA. Although we do not anticipate any new hires in Site I before the program closes on 12/31/17, all potential hires will have a criminal history check completed and the information will be verified by the MH/ID Compliance Monitor prior to hire date. 07/17/2017 Implemented
SIN-00094916 Renewal 06/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(h)Staf #3, #4, and #5's record of training had no record that they were training on individual #3's communiucation plan. 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.Several staff were absent from the training and that was overlooked. The Program Coordinator has created a sign in form identifying all who must be trained so that absences are readily apparent. In those cases, staff will be trained upon return. The staff who were not trained on the communication plan for #3 have been trained. The file review checklist has been updated to include these requirements. 07/25/2016 Implemented
2380.111(c)(5)Individal #3's Tuberculin test dated 1/16/15 and 1/17/13 did not state who read the results. 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.the client physical exam form has been revised to require the signature of the person who administered and read the TB test. The file review checklist has been updated to include a check on this section. Staff are being retrained regarding the requirement and the use of the form(s). 07/29/2016 Implemented
2380.111(c)(7)Individual #2's physical dated 3/16/16 did not have health maintaince needs listed. It was blank on the physical. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.the MH/ID Compliance Monitor has revised the physical exam form to more clearly indicate requirements. The MH/ID Compliance Monitor has revised the file review checklist to include these specific items; and the Monitor is retraining staff on use of the forms. 07/29/2016 Implemented
2380.173(9)Individual #2's emergency information sheet states no allergies. The physcial dated3/16/16 states allergic to celclor and seasonal allergies. The assessment states he uses a wheelchair for long distances but nothing is listed under physical limitations on the physcial. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The emergency information sheet that was cited was only an update page for the current year; the actual medical history that was attached as part of the emergency packet does list both allergies. The update page will be redesigned to clearly indicate that it is part of a larger packet of emergency information. The assessment and the ISP both state that a wheelchair is to be used for distances. The statement has been added to the physical. This has been added to the file review checklist for content discrepancy. 07/28/2016 Implemented
2380.185(b)Individual #3's ISP outcome to decrease injurious behaviors has not been implemented. The ISP shall be implemented as written.Individual #3 has a one on one support staff as part of the implementation to decrease self injurious behaviors, and that staff person has started daily documentation of behaviors and interventions. All staff have been retrained on the individual's SEEN plan, and methodology to decrease behaviors. All client ISP's are being reviewed to assure that all outcomes pertinent to the program day are implemented. 07/26/2016 Implemented
2380.186(c)(2)Individual #3's ISP reviews dated 5/26/16, 2/16/16, and 11/15/15 did not review the SEEN plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Quarterly review form has been revised to specifically address any specialize needs or plans for the individual. The file review checklist has been updated to more directly clarify what should be included in this area. Staff are being retrained on the requirements and new format. 07/29/2016 Implemented
SIN-00073848 Renewal 04/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(b)During the fire drill conducted today about 5 or more staff from another building that aren't counted in the staffing ratio for the day program, came over to assist with the fire drill.Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average.  Implemented
2380.127(a)(4)Staff #2's medication administration training expired in January 2015. Staff #2 continued to administer medications in February, March, and April 2015. Staff #4 did not complete the entire annual medication administration training. Staff #4 only completed observations. She has not been certified to administer medications since 6/12/14 and she has been administering medications.Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: A staff person who meets the criteria in §  2380.128 (relating to medication administration training), for the administration of oral, topical and eye and ear drop prescription medications and insulin injections.  Implemented
2380.128(a)Staff #2 had annual medication administration completed on 1/13/14 and not again yet. She was due on 1/13/15 and annual licensing survey was completed on 4/6/15. Staff #4 was due for her annual medication administion training on 6/12/14 but has not completed it yet. A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.  Implemented
2380.181(d)The program specialist did not sign and date the assessment for Individual #2.The program specialist shall sign and date the assessment.The assessment has been signed and dated. The Manager of Community Skills has retrained the Program Specialists regarding the requirement of signatures and dates on all documentation. This requirement for all legal documentation is now emphasized in the mandatory training on Billing and Documentation as well. The Program Specialist has reviewed all files to ensure signatures and dates are on all applicable documents. 07/31/2015 Implemented
2380.181(e)(5)The assessment for Individual #1 did not include their ability to self-administer medications.The assessment must include the following information: The individual¿s ability to self-administer medications.The Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) ability to identify medication, tell correct time, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is reviewing files to determine if current assessments require addendums to address all required components. 07/31/2015 Implemented
2380.181(e)(13)(i)The assessment for Individual #1 did not contain progress and growth in 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) routine medical assessments or appointments, general health stable, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. 07/31/2015 Implemented
2380.181(e)(13)(ii)The assessments for Individuals #1 and #3 did not contain progress and growth in 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) dexterity, ability to make needs and wants known, ability to navigate safely through an area, etc.. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. 07/31/2015 Implemented
2380.181(e)(13)(iii)The assessment for Individual #1 did not contain 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) the individual¿s ability to interact successfully with the community and others around him etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. 07/31/2015 Implemented
2380.181(e)(13)(iv)The assessment for Individual #1 did not contain 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) ability to successfully demonstrate social skills in the community. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. 07/31/2015 Implemented
2380.181(e)(13)(v)The assessment for Individual #1 did not contain 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) interest in participating in recreational activities, preferred recreation, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. 07/31/2015 Implemented
2380.181(e)(13)(vi)The assessment for Individual #1 did not contain 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 Manager of Community Skills has retrained the Program Specialists regarding the need for information in this section, including (example) amount of time tolerated in community environments, willingness to participate in community activities, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. 07/31/2015 Implemented
2380.182(d)(4)There was no documentation that an Individual Support Plan (ISP) invitation was sent to team members for Individual # 2.The plan lead shall develop, update and revise the ISP according to the following: An invitation shall be sent to plan team members at least 30 calendar days prior to an ISP meeting.The Manager of Community Skills has retrained the Program Specialists 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. 07/31/2015 Implemented
2380.183(7)(iii)The Individual Support Plan (ISP) for Individual #3 did not include an assessment of their potential to advance in competitive community-integrated employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.The ISP for Individual #3 contains a statement in the Educational/Vocational section that Individual #3 expresses no interest in having an employment goals at this time due to his retirement age and poor eyesight¿ . Individual #3 is 66 years old and now legally blind in addition to significant functional limitations. However there is no corresponding statement in the Employment/Volunteer information section. Supports Coordinators will be advised at all ISP meetings that the section must be addressed to meet regulatory compliance. The Manager of Community Skills has retrained the Program Specialists regarding the requirement this information is contained in the ISP. The Program Specialist is reviewing individual ISPs to determine if changes must be requested of the SC. 07/31/2015 Implemented
2380.187Individual #2's Individual Support Plan (ISP) meeting was held on 11/11/14 and not sent to team members until 1/9/15. Individual #1's ISP meeting was held on 9/9/14 and was not sent to team members until 10/28/14.A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP annual update and ISP revision meetings.The Manager of Community Skills has retrained the Program Specialist regarding the requirement and the necessity of contacting the SC to remind him/her of the need for Goodwill to have the ISP within 30 days. Licensing inspectors recommended this reminder contact be made as soon as possible after the ISP meeting rather than wait until closer to the 30 day limit, and documented appropriately, Program Specialists have been instructed to make this a regular practice. 07/31/2015 Implemented
SIN-00060267 Renewal 02/19/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)The Turberculin skin testing for staff person #3 was late, 2/5/11 then 3/22/13. (c)  The physical examination shall include:(2)  Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.4/11/14 CSS Partially Implemented/Adequate Progress This was discovered by Goodwill staff in March of 2013, and tracking measures were put into place at that time to prevent a reoccurrence. These include the Program Specialist tracking due dates for staff physicals and TB testing on a spreadsheet, with calendar reminders. All staff have had both the physical and the TB test within the required time frame since 3/2013. Supplemental documentation will be submitted via email. 05/01/2014 Implemented
2380.128(a)Staff person #1 began to administered medications on 6/6/13, 6/7/13 & 6/10/13 but did not complete and pass the Departments Medications Administration Course until 6/12/13. Staff is not permitted to administer medications until after the Medication Administration Course is completed and has passed. (a)  A staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.*** Still needs varification of the medication training was completed 4/29/14 CSS *** MH/ID compliance monitor is completing the Train the trainer medication administration training. Upon completing the training, MH/ID Compliance Monitor will set up process and controls to prevent recurrence. The MH/ID Compliance Monitor will train additional staff in medication administration, and additional staff will be trained to be trainers. We plan to have two trainers in addition to the Compliance Monitor by Fall of 2014 and will then be able to successfully train and recertify staff to administer meds on an ongoing basis. 10/01/2014 Implemented
2380.128(e)Staff person #2 was administering medication to Individuals and there was no documentation of the Annual Practicums kept for 2012 & 2013. (e)  Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.MH/ID compliance monitor is completing the Train the trainer medication administration training. Upon completing the training, MH/ID Compliance Monitor will set up process and controls to prevent recurrence. The MH/ID Compliance Monitor will train additional staff in medication administration, and additional staff will be trained to be trainers. We plan to have two trainers in addition to the Compliance Monitor by Fall of 2014 and will then be able to successfully train and recertify staff to administer meds on an ongoing basis. 10/01/2014 Implemented
2380.181(e)(13)(i)The Health section in the annual assessment for Individual #2did not contain progress over the last 365 calendar days. (e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (i)   Health.4/11/14 CSS Partially Implemented/Adequate Progress Program Specialists were reinstructed on 3/11/14, regarding the required content of the assessment. These instructions included: 1. Completion of interim progress notes documenting issues/situations of note between monthly progress notes. 2. Using the monthly progress notes, interim notes, and quarterly reviews as part of the information gathering and double check on content in the assessment to insure all pertinent information is included. Program Specialists will conduct biweekly audits of each other¿s file using the licensing documentation checklist. An addendum to the assessment for Individual #2 has been completed. See supplemental documents. 05/01/2014 Implemented
SIN-00045702 Renewal 02/26/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)The physical for Individual #1 was completed on 12/9/11, but then not again until 12/31/12. This exceeds the annual regulatory requirement.(a)  Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.PARTIALLY IMPLEMENTED, INADEQUATE PROGRESS. JW 4/4/2013 1. Program Specialists were re-instructed by the MH/ID Compliance Monitor, regarding the need to have the physical annually for all individuals, and the maximum 15 day ¿grace¿ period for compliance in all applicable documentation. (completed) In this particular instance the Program Specialist tried to make the physical due for Goodwill coincide with the one due for Case Management since the family was having difficulty complying with the requirements. 2. Program Specialists are reviewing all client documentation and will add any information missing from the original document as addendum. (Target date 3/31/13) 3. MH/ID Compliance monitor is developing a calendar based tracking system that will track the due dates for physical examinations, TB testing and Annual Assessments through the course of the year. The tracking calendar will be monitored by the Program Specialists and the Manager of Community Skills. (Target Date 4/15/13) 3. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 1. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 2. Training of all Program Specialists in use of the checklist. Target: 4/15/13 3. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13) 4. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 5. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/13/2013 Implemented
2380.111(c)(6)The physical for Individual #1, dated 12/31/12, did not include if she was free from communicable diseases. (c)  The physical examination shall include:(6)  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.PARTIALY IMPLEMENTED, INADEQUATE PROGRESS. JW 4/4/2013 1. Program Specialists are reviewing all client documentation and will add any information missing from the original document as addendum. (Target date 3/31/13) Individual #1¿s physical has been amended to include the response to the questions regarding communicable diseases. In this instance, the individual¿s family was not compliant with providing the information when requested. The immediate correction is that no individual will be allowed to attend the program after the due date until the necessary information is received. 2. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 1. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 2. Training of all Program Specialists in use of the checklist. Target: 4/15/13 3. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13) 4. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 5. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2380.181(a)The assessment for Individual #1 was completed on 4/3/11, but then not again until 5/9/12. This exceeds the annual regulatory requirement. (a)  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.PARTIALLY IMPLEMENTED, INADEQUATE PROGRESS. JW 4/4/2013 1. Program Specialists were re-instructed by the MH/ID Compliance Monitor, as to the requirements of the annual assessment. In this particular instance the confluence of both the Manager and the Program Specialist being on medical leave of absences created a situation where no one acting as substituting PS had easy access to the necessary information. MH/ID Compliance monitor is developing a calendar based tracking system that will track the due dates for physical examinations, TB testing and Annual Assessments through the course of the year. The tracking calendar will be monitored by the Program Specialists and the Manager of Community Skills, but will also be available as clear documentation should another situation arise and someone has to ¿step in¿ as PS on short notice. 2. Program Specialists are reviewing all client documentation and will add any information missing from the original document as addendum. (Target date 3/31/13) 3. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 6. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 7. Training of all Program Specialists in use of the checklist. Target: 4/15/13 8. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13) 9. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 10. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2380.181(e)(13)(vi)The assessment for Individual #2 did not include progress and growth in community integration. (e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (vi)   Community-integration.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013 A specific question regarding the progress in the area of Community ¿ Integration has been added to the Adult Training Facility Assessment form. (completed) An addendum has been added to Individual ¿2¿¿s assessment to incorporate the information. (in process) The entire assessment format is being reviewed by the MH/ID Compliance Monitor for compliance with the language of the actual regulations rather than the LII. (in process) The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 1. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 2. Training of all Program Specialists in use of the checklist. Target: 4/15/13 3. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13) 4. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 5. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2380.181(f)The assessment for Individual #2, dated 7/10/12, was not sent to plan team members. (f)  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).PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013 The Program Specialists were retrained by the MH/ID Compliance Monitor that the assessment must be sent to all plan team members at least 30 days prior to the ISP meeting, rather than just the Supports Coordinator. The assessment form itself is being modified by the MH/ID Compliance Monitor to include specific instructions about who must receive copies of it and the time frames. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 1. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 2. Training of all Program Specialists in use of the checklist. Target: 4/15/13 3. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13) 4. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 5. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2380.186(b)Individual #1 did not sign and date the ISP reviews dated 11/15/12 and 8/13/12. (b)  The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013 The specific documents in question have been reviewed with the individual and signed as of now. A new format for the ISP review has been developed by the MH/ID Compliance Monitor and will be put into use as of 4/1/12; the new format more closely follows the ISP and clearly indicates the need for the signatures. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 6. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 7. Training of all Program Specialists in use of the checklist. Target: 4/15/13 8. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13) 9. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 10. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2380.186(d)The May and August 2012 ISP reviews for Individual #2 were not sent to plan team members. (d)  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 meetingPARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013 The Program Specialists were re-trained regarding the requirement to send the reviews out within 30 calendars after the meeting with the client, (barring the team member declining the reviews), by the MH/ID Compliance Monitor. Several reviews have occurred since the site visit and the reviews have been sent out within required time frames. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: 11. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 12. Training of all Program Specialists in use of the checklist. Target: 4/15/13 13. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13) 14. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 15. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented