| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Who: CEO
What: A self-assessment will be conducted at the residential site to comply with 55 PA Code Chapter 6400.15(a) regulations.
When and How: 10/31/2016, The CEO will utilize the self-assessment tool to determine and document site compliance/non-compliance.
Target Date:10/31/16
Long-term plan: CEO will use an alert system that will notify self and Program Specialist of renewal date for the self-assessment. |
10/31/2016
| Implemented |
| 6400.46(a) | Staff #1 and staff #8 were not oriented prior to working with the individual. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Who: Program Specialist
What: Residential orientation training syllabus was formulated and staff received site specific training covering their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions.
When and How: 9/27/16, new staff received site specific orientation per regulation requirements.
Completion Date: 9/27/16
Long-term plan: All residential staff will be retrained on the site specific policy and procedures and Program Specialist will document completion of training. This documentation will be kept in staff file.
Target Date: 12/4/16 |
09/27/2016
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Who: Program Specialist
What: Thermometers were purchased and labeled with each individual¿s name and placed inside first aid kits.
When and How: On 08/22/16, staff purchased thermometers. Thermometers were labeled and placed inside respective first aid kit.
Completion Date: 08/22/16
Long-term plan: A first Aid kit checklist will be formulated to track and ensure specified items are maintained in the first aid kits according to regulations. This checklist will be reviewed monthly and signed off by staff and the Program Specialist to ensure accuracy and compliance. |
08/22/2016
| Implemented |
| 6400.112(a) | A fire drill held on 2/27/16 was not unannounced. | An unannounced fire drill shall be held at least once a month. | Who: Program Specialist
What: All fire drills conducted since audit findings were unannounced.
When and How: On 08/23/16 and 09/09/16, Program Specialist conducted unannounced fire drills. Direct Staff and individuals exited within required timeframe and remained at designated area until all-clear was given.
Completion Date: 08/24/16, 9/09/16
Long-term plan: Only person conducting fire drill will be aware of the fire drill. Staff will be counseled on importance of keeping fire drills unannounced. |
08/24/2016
| Implemented |
| 6400.141(c)(14) | Individual #2's physical examination on 8/19/15 did not contain information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Who: Program Specialist
What: The annual physical form was resent to the individual¿s PCP with request to complete all sections of the form per 55 PA Code Chapter 6400.141 specifications.
When and How: On 08/22/16, Program Specialist resent physical form to PCP office to have remainder of form completed as specified. The form was returned but still incomplete so the PCP office was contacted again to review and complete remaining sections on 09/14/16. A second follow-up occurred on 09/29/16.
Target Date: 10/15/16
Long-term plan: When individual goes to conduct annual physical, direct staff will ensure that the entire form is filled out and reach out to PCP and/or Program specialist if information is lacking. PCP will be reminded of need to complete form in its entirety to ensure compliance with 55 PA Code Chapter 6400.141. |
10/14/2016
| Implemented |
| 6400.142(f) | Individual #2's record did not contain a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Who: Program Specialist
What: A pre-visit plan was completed by the individual¿s dentist.
When and How: On 08/24/16, Program Specialist filled out appropriate sections of dental pre-visit form and faxed to individual¿s dentist. The dentist completed the appropriate remaining sections and resent form to Program Specialist.
Completion Date: 08/24/16
Long-term plan: The interdisciplinary team will discuss dental hygiene plan and conduct continuous assessments to gauge level of individual achieving hygiene independence. |
08/24/2016
| Implemented |
| 6400.151(a) | Staff #2's most recent physical exam was completed on 1/24/14 Staff #5's most recentphysical was dated 5/06/14.
Staff #7 did not have a current physical exam.
| A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Staff #3 did not have an physical exam prior to becoming employed. | Who: HR Consultant
What: Staff #2, #5 and #7 completed current physical exam with documentation.
When and How: On 09/29/16, staff #2 had physical exam. On 09/30/16, staff #5 had physical exam. On 10/01/16, staff #7 had physical exam.
Completion Date: 10/01/16
Long-term plan: A physical due date tracking alert will be added to notify in advance when physicals are due to stay in compliance with ODP regulations. |
10/01/2016
| Implemented |
| 6400.151(c)(1) | Staff #4's annual physical dated 10/14/15 did not include a general physical examination.
Staff #6's annual physical dated 11/23/15 did not include a general physical examination.
| The physical examination shall include: A general physical examination. | Who: HR Consultant
What: Physical forms were updated to be compliant with 6400 policies. Staff information was completed and/or updated for applicable need per 55 PA Code Chapter 6400.151(c)(1).
When and How: As of 08/25/16, HR reached out to and communicated with ARIA Health to collaborate on form revisions to achieve compliance with all required documentation including general physical examination information.
Completion Date: 09/20/16
Long-term plan: Designated QM staff will review new Bulletins and alert for any needed updates to the annual physical form. Revisions will be made to ensure compliance. This process will be included and recorded in our monthly QM documents. |
09/20/2016
| Implemented |
| 6400.151(c)(2) | Staff #5's most recent TB test was completed on 5/09/14. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if 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, licensed physician's assistant or certified nurse practitioner. | Who: HR Consultant
What: Staff #5 had a 2-step TB completed on 02/18/16.
When and How: HR rechecked files and confirmed that staff had a recent completed and compliant TB test.
Completion Date: 02/18/16
Long-term plan: HR staff will ensure that TB records are current, on file, and available for review when requested. |
02/18/2016
| Implemented |
| 6400.151(c)(3) | Staff #4's annual physical examination dated 10/14/15 did not include if the individual was free from communicable disease.
Staff #6's annual physical dated 11/23/15 did not include if the individual was free from communicable disease.
| The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Who: HR Consultant
What: Physical forms were updated to be compliant with 6400 policies. Staff information was completed and/or updated for applicable need per 55 PA Code Chapter 6400.151(c)(1).
When and How: As of 08/25/16, HR reached out to and communicated with ARIA Health to collaborate on form revisions to achieve compliance with all required documentation including general physical examination information.
Completion Date: 09/20/16
Long-term plan: Designated QM staff will review new Bulletins and alert for any needed updates to the annual physical form. Revisions will be made to ensure compliance. This process will be included and recorded in our monthly QM documents. |
09/20/2016
| Implemented |
| 6400.151(c)(4) | Staff #4's annual physical dated 10/14/16 did not include information regarding medical problems.
Staff #6's annual physical exam dated 11/23/15 did not include information regarding medical problems.
| The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Who: HR Consultant
What: Physical forms were updated to be compliant with 6400 policies. Staff information was completed and/or updated for applicable need per 55 PA Code Chapter 6400.151(c)(1).
When and How: As of 08/25/16, HR reached out to and communicated with ARIA Health to collaborate on form revisions to achieve compliance with all required documentation including general physical examination information.
Completion Date: 09/20/16
Long-term plan: Designated QM staff will review new Bulletins and alert for any needed updates to the annual physical form. Revisions will be made to ensure compliance. This process will be included and recorded in our monthly QM documents. |
09/20/2016
| Implemented |
| 6400.161(a) | Individual #1 is prescribed, Divalproex and Chlorpromazine, which were not kept in their original containers. | Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or weekly dispensing containers. | Who: Program Specialist
What: Medications were returned to their original containers.
When and How: On 8/19/16 prior to 8pm, Program Specialist oversaw transfer of medications from pillbox back to original containers.
Completion Date: 08/19/16
Long-term plan: Medication will continue to remain in original containers or blister packs as received unless and until the individual is deemed to be self-medicating. |
08/19/2016
| Implemented |
| 6400.169(a)(1) | Indivdiual #1's annual assessment dated 6/10/16 documents assistance is needed in the recognition and time identification of medication administration. However, Indivdual #1 has been self-medicating. | To be considered capable of self-administration of medications an individual shall: Be able to recognize and distinguish the individual's medication. | Who: CEO
What: Contracted with LPN to provide necessary medication administration for individual #1.
When and How: On 8/19/16, an LPN was contacted and contracted with to provide immediate medication administration to individual #1 as of 8pm on 8/19/16 following audit determination of need. LPN services are in place until direct support staff are med certified per ODP compliance standards.
Completion Date: 8/19/16
Long-term plan: Direct staff will complete and pass the Department¿s Medications Administration Course and be able to administer oral, topical and eye and ear drop prescription medications to individuals who do not self-medicate. Individuals will have goals focused on medication administration and be supported in learning to self-medicate if possible. A continuous assessment will be completed to gauge the individual¿s ability to self-medicate.
Target Dates: Medication Training completion (10/31/16) |
11/30/2016
| Implemented |
| 6400.217 | Individual #1 did not have a release of medical information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Who: Program Specialist
What: Release of medical information form was reviewed and signed off on by individual.
When and How: On 8/22/16, individual signed form indicating agreement on release of information policy. All other individual files were reviewed and corrected (if necessary) according to the stated corrective action plan. The medical release form was added to ISP intake packet for residential program.
Completion Date: 08/22/16
Long-term plan: An intake checklist will be created to ensure all components of intake documentation process are completed. The intake packet information will be reviewed against the intake checklist by the CEO to ensure accuracy per 55 PA Code Chapter 6400.217 compliance standards. |
08/22/2016
| Implemented |