| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The written fire drill records for the fire drills held on 7/30/18, 9/9/18, 12/7/18, 1/27/19, 4/30/19 do not address problems encountered; this section was left blank. | 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 or smoke detector was operative. | Historically, we have instructed staff to document on the fire drill only if there was a problem encountered. If nothing occurred, there would be no documentation in this section. This has been our process for many years. It has not been discussed with us during any previous licensing inspection that we were not meeting the regulation or that we needed to consider making any changes. This would have been greatly appreciated, as we always value the guidance received during inspections and have made adjustments as needed.
Going forward, all staff at all homes will be instructed to document ¿none¿ under ¿Problems Encountered¿ if there is no occurrence to be documented. Specialists will be trained by the Associate Director on 7/1/19. In turn, Specialists will train the Supervisors and they will train the DSPs. This training will be completed by 7/31/19.
We will continue our current fire drill review process with an emphasis on no part of the documentation being left blank. The Supervisor of each home will review the Fire Drill to ensure that staff running the drill has completed the documentation in its entirety. The Supervisor will present the drill to the Specialist, who will also review the drill for accuracy and completion. The drill will then be submitted to the next reviewer, who will do the same. The Associate Director, Community Living will then complete a final review of the drill before filing. |
07/31/2019
| Implemented |
| 6400.192 | The agency is currently using a training document from Allegheny County as the restrictive procedure policy. | A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the home.
| Community Supported Living is creating a Restrictive Procedure Policy that adheres to, but is separate from the ODP Bulletin. The Training and Development Manager will complete the written policy by 7/1/19. Specialists will be trained by the Associate Director on 7/1/19. In turn, Specialists will train the Supervisors and they will train the DSPs. This training will be completed by 7/31/19. |
07/31/2019
| Implemented |
| 6400.194(c) | The restrictive procedure review committee held a meeting 7/31/18 and then again on 02/05/19 for review of restrictive procedure plan for Individual #1. | The restrictive procedure review committee shall establish a time frame for review and revision of the restrictive procedure plan, not to exceed 6 months between reviews.
| The Restrictive Plan Review for the Person was to be completed on 1/31/19. The HRC Chairperson held the HRC meeting on 2/5/19. She did not realize that there is no grace period for six month reviews of the Plan. This was reviewed with her by the Vice President, Community Supported Living at the conclusion of licensing. The next Plan review for this Person is scheduled for 8/5/19, which meets the six month requirement. Specialists are also responsible to ensure that reviews are scheduled and completed within the six month time frame. They are to contact the Associate Director should a review need to occur sooner than scheduled. Specialists will be trained by the Associate Director on 7/1/19. |
08/05/2019
| Implemented |
| 6400.196(b) | The direct service workers and program specialists responsible for developing, implementing, or managing Individual #1's restrictive procedure plan were not trained in the use of specific techniques or procedures that are used. | A staff person responsible for developing, implementing or managing a restrictive procedure plan shall be trained in the use of the specific techniques or procedures that are used.
| Staff had received training on the Person¿s Restrictive Procedures Plan as part of the ISP training. A separate training agenda was not completed. All staff will be re-trained in the Person¿s Restrictive Procedure Plan by 7/31/19. Going forward, Staff will receive ISP training, along with a separate training completed for any Person that has a Restrictive Procedures Plan. Each training will be documented on its own Training Agenda form. All Specialists will be made aware of this by the Associate Director on 7/1/19. |
07/31/2019
| Implemented |