| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.91(a) | Individual #1 was admitted on 4/4/2017. She did not receive fire safety training until 4/11/2017. Individual #2 was admitted on 11/17/2016. He did not receive fire safety training until 11/24/2016. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | The Program Specialist has reviewed the requirement for conducting initial fire safety training upon initial admission. All individuals will be trained in fire safety on the first day of admission. This requirement has been reviewed with all Program Specialists. The Program Specialist and Program Manager are responsible for ensuring this training is completed. |
09/22/2017
| Implemented |
| 2380.111(c)(2) | This section was not on Individual #2's physical exam dated 11/7/2016. | The physical examination shall include: A general physical examination. | A new physical exam was completed for this individual on 09.20.2017 which includes a general physical exam.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specialist is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.111(c)(3) | This section was not on Individual #2's physical exam dated 11/7/2016. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | A new physical exam was completed for this individual on 20 September which includes this information.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.111(c)(4) | This section was not on Individual #2's physical exam dated 11/7/2016. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | A new physical exam was completed for this individuall on 20 September 2017 which included this information.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.111(c)(6) | This section was not on Individual #2's physical exam dated 11/7/2016. | 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. | A new physical exam was completed for this individuall on 20 September 2017 which included this information.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.111(c)(7) | This section was not on Individual #2's physical exam dated 11/7/2016. Health maintenance needs was not on Individual #1's physical exam dated 2/20/2017. | 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. | A new physical exam was completed for this individuall on 20 September 2017 which included this information.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.111(c)(8) | This section was not on Individual #2's physical exam dated 11/7/2016 and Individual #3's physical exam dated 7/12/2017. | The physical examination shall include: Physical limitations of the individual. | A new physical exam was completed for this individuall on 20 September 2017 which included this information.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.111(c)(9) | This section was not on Individual #2's physical exam dated 11/7/2016. | The physical examination shall include: Allergies or contraindicated medication. | A new physical exam was completed for this individuall on 20 September 2017 which included this information.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.111(c)(10) | This section was not on Individual #2's physical exam dated 11/7/2016 and Individual #3's physical exam dated 7/12/2017. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A new physical exam was completed for this individuall on 20 September 2017 which included this information.
A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. |
09/20/2017
| Implemented |
| 2380.181(a) | Individual #2 was admitted to this program on 11/17/2016. He did not have an initial assessment completed until 1/23/2017. Individual #3 had an assessment completed on 3/28/2016. He did not have another assessment until 8/9/2017, which exceeds the annual requirement. | 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. | The Program Specialist has reviewed the requirements for initial and annual assessments. All assessments have been reviewed to ensure they have been completed in the proper timeframes. All Program Specialists are responsible for completion of the assessment in the correct timeframe. |
09/22/2017
| Implemented |
| 2380.181(e)(1) | This area was not evaluated in Individual #3's assessment dated 8/9/2017. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | An updated assessment for Individual #3 was completed on 09.07.2017 which includes information on functional strengths, needs and preferences of the individual. All assessments have been reviewed to ensure they contain the appropriate and required information. The Program Specialist is responsible for the accurate completion of the assessment. |
09/07/2017
| Implemented |
| 2380.181(e)(2) | This area was not evaluated in Individual #3's assessment dated 8/9/2017. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | An updated assessment for Individual #3 was completed on 09.07.2017 which includes information on the likes, dislikes and interests of the individual, including vocational and employment interests. All assessments have been reviewed to ensure they contain the appropriate and required information. The Program Specialist is responsible for the accurate completion of the assessment. |
09/07/2017
| Implemented |
| 2380.181(e)(12) | This area was not evaluated in Individual #3's assessment dated 8/9/2017. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | An updated assessment for Individual #3 was completed on 09.07.2017 which includes information on recommendations for specific areas of training, vocational programming and competitive community integrated employment. All assessments have been reviewed to ensure they contain the appropriate and required information. The Program Specialist is responsible for the accurate completion of the assessment. |
09/07/2017
| Implemented |
| 2380.186(a) | Individual #3 had ISP Reviews on 8/6/2016, 11/8/2016, 1/23/2017, 4/28/2017, and 8/16/2017. The timeframe between 4/28-8/16/2017 exceeds the 3 month requirement. | 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. | An ISP review was completed using information from 07.28.2017 to address the gap. The Program Specialist has reviewed all ISP reviews to ensure the time frames are appropriate. The Program Specialist is responsible for ensuring that the timeframe between quarterly reviews does not exceed three months. |
09/22/2017
| Implemented |
| 2380.186(b) | Individual #3's ISP Review dated 8/16/2017 was not signed by the individual or the program specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The ISP review from 08.16.2017 has been signed by the individual and program specialist. THe ISP reviews for all individuals have been reviewed to ensure they have the proper signatures. The Program Specialist is responsible for ensuring ISP reviews are signed. |
09/22/2017
| Implemented |