| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #5 did not have a physical exam is 1/20/2021 completed prior to their admission on 9/1/2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Upon admission, an annual physical was not provided to SCS; however, after multiple attempts to get a copy of a 2020 annual physical form from his family without success, SCS set Individual #5 with a new PCP in Berks and got his annual physical completed on 1/20/21. Moving forward, SCS will ensure that all needed documents are provided prior to admission. The admission will be delayed if necessary. |
03/15/2022
| Implemented |
| 6400.141(c)(4) | Individual #5's physical exam dated 1/20/21 hearing screening section was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The physical exam for Individual #5 was resubmitted to the health care provider and revised to have the hearing screening section completed. |
11/20/2021
| Implemented |
| 6400.141(c)(11) | Individual #5's physical exam dated 1/20/21 health maintenance needs section was left blank. | 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 physical exam for individual #5 was returned to the health care provider to have the health maintenance section of the annual physical form competed. |
11/20/2021
| Implemented |
| 6400.143(a) | Individual #5 was uncooperative at their dental exam on 10/15/20 and on 8/25/21 a limited dental cleaning occurred due to Individual #5 being uncooperative. There is no documentation that the agency has trained individual #5 on the importance of dental exams. Individual #5 went to a vision exam on 10/27/21 but refused to wear a mask, and the health care provider cancelled his appointment due to him not wearing it. There is no documentation that Individual #5 was trained on the importance of wearing a mask and having a vision exam. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #5 has been trained on the importance of wearing a mask as well as the need for routine dental exams and vision exams. Refusal forms will be used to document any refused appointments and education will be provided to the individual regarding the importance of maintaining medical appointments. Documentation will be kept in Extended Reach of the refused appointments and training provided to the individual. |
02/15/2022
| Implemented |
| 6400.52(c)(1) | Staff #4 did not receive annual training on the application of person-centered practices, community integration, individual choice and supporting individuals 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. | Staff was trained on the Everyday Lives Policy on 9/10/21 as part of his annual training hours. Threse documents have been uploaded into his employee profile at this time. All employee files have been reviewed to ensure compliance with orientation and annual training guidelines on the following topics: Application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, Individual Rights, recognizing and reporting abuse, incident reporting, implementation of the individual plan, understanding and implementing behavioral support plan, and refusal of treatment. |
03/16/2022
| Implemented |
| 6400.52(c)(3) | Staff #4 did not receive annual training on Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff was trained on the Everyday Lives Policy on 2/18/22 as part of his annual training hours. Documents have been uploaded into his employee profile at this time. All employee files have been reviewed to ensure compliance with orientation and annual training guidelines on the following topics: Application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, Individual Rights, recognizing and reporting abuse, incident reporting, implementation of the individual plan, understanding and implementing behavioral support plan, and refusal of treatment. |
03/16/2022
| Implemented |
| 6400.52(c)(6) | Staff #4 did not receive annual training on the implementation of the individual plan. | 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. | Staff was trained on the importance of the individual's ISP and implementation of such during his 24 hour shadowing checklist review on 9/8/21. Staff also signed the ISP Acknowledgement on 9/8/21 when the ISP was reviewed. This documentation has also been uploaded into the employee's file. All employee files have been reviewed to ensure compliance with orientation and annual training guidelines on the following topics: Application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, Individual Rights, recognizing and reporting abuse, incident reporting, implementation of the individual plan, understanding and implementing behavioral support plan, and refusal of treatment. |
03/16/2022
| Implemented |
| 6400.165(g) | Individual #5's 3-month psychiatric appointments on 10/15/21, 7/21/21, and 3/30/21 did not include documentation on the reason for prescribing the medications. Individual #5 had a 3-month psychiatric appointment on 3/30/21 and their next appointment occurred on 7/21/21 which exceeds the required timeframe. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #5's provider rescheduled his appointment in June which led to being out of compliance when his follow up appointment was completed on 7/21/21. House Managers and Program Specialists are responsible for the oversight of all medical appointments and ensuring that appointments are completed within the designated time frames.. Moving forward, House Managers and Program Specialists will review documentation within 24 hours of appointment to ensure documentation includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Program Specialist will follow up with providers as needed to obtain any missing documentation. |
03/01/2022
| Not Implemented |