Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232900 Renewal 10/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.83(a)The Emergency Evacuation Policy includes a relocation site that is no longer in operation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.This occurred due to TLC merging day program locations in York County and failing to update TLC Policy 0200-012 Emergency Evacuation Policy. The policy has been updated to remove the Emigsville location as of 11/15/2023 and is attached as "TLC Emergency Evacuation Policy." The outdated policy was removed from all TLC Fire Binders in Day Program locations effective 11/15/2023. 11/15/2023 Implemented
2380.87(d)The "fire safety procedures and monitoring" plan is written for a Residential facility and not an Adult Training facility and does not include what specific monitoring plan is in place in the event of an inoperable fire alarm system.There shall be a written procedure for firesafety monitoring in the event the fire alarm is inoperative.This occurred due to lack of training on the regulatory components of a written procedure for fire safety monitoring in the event the fire alarm is inoperative. TLC has updated their Practice and Guidelines for location specific fire safety procedures and monitoring (see attached "TLC Gettysburg Fire Safety and Emergency Response" for Gettysburg Day Program and "TLC York Fire Safety and Emergency Response" for York Day Program). The updated plan includes procedures specific to an Adult Training Facility. The new plan notes that in the event the fire alarm is inoperative, the TLC Day Program location will close for the day and remain closed until the fire alarm is repaired. While awaiting closure (for people in supports to be picked up), TLC staff will be assigned to specific areas of the building and monitor periodically (approximately every 15 minutes) for signs of smoke/fire. If staff recognize any signs of fire, all individuals will be immediately evacuated and 911 will be notified. Upon repair of the fire system, TLC staff will run a fire drill to ensure all alarms are in working condition prior to re-opening the facility. 11/16/2023 Implemented
2380.111(c)(1)Individual #2's 10/26/22 Physical Exam did not include a review of Individual #2's previous medical history, this section of the form was left blank by the attending physician.The physical examination shall include: A review of previous medical history.This occurred due to lack of staff training on reviewing Annual Physicals after completion and the design of the Annual Physical Form that was utilized at the time of Individual #2's 2022 Annual Physical. The form has since been updated to include a section where the Program Specialist signs off, they have reviewed the form in its entirety, and it is complete in compliance with 2380 regulations, including lifetime medical history information. The current 2023 Annual Physical (see attached "Individual #2 Annual Physical 11 08 2023") contains a lifetime medical history on pages 7 and 8 under "medical history" and "surgery history." 11/16/2023 Implemented
2380.171(b)(2)Individual #2's record does not include Individual #2's medical care contact information (doctor or medical group) to contact in case of a medical emergency.Emergency information for each individual shall include: The name, address and telephone number of the individual's physician or source of health care.This occurred due to lack of training on the regulatory components of the individual record. Individual #2's record was immediately corrected (11/1/2023) to reflect the name, address and telephone number of the individual's source of health care (see attached "Individual #2 Face sheet). An audit of all TLC Day Program Face sheets will be conducted by 11/30/2023 to individual's medical care contact information is present; if information is missing it will be added immediately. 11/30/2023 Implemented
2380.181(e)(14)Individual #2's 03/07/23 Assessment states that they "understand water safety" but cannot temper their own water due to sensory concerns. The assessment does not identify if the individual has the ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.This occurred due to a lack of process to ensure Annual Assessments are completed in compliance with regulatory requirements. An Annual Assessment Addendum was completed on 11/15/2023 to clarify Individual #2's ability to swim and understand water safety. The Annual Assessment Addendum now indicates "no" to individual understands water safety with an explanation that, "Individual cannot temper their bath/shower water. They often prefer their water to be too hot, which it is suspected may be a sensory preference." Additionally, the Annual Assessment Addendum now indicates "no" to individual is able to swim with an explanation that, "the individual can swim but should be supervised around larger bodies of water." 11/15/2023 Implemented
SIN-00215751 Renewal 12/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)REPEAT from January 2022 inspection- 59b- Water temp in the female bathroom sink registered on the thermometer was 128.1F.Hot water temperatures in areas accessible to individuals may not exceed 120°F.TLC corrected this immediately while ODP was on site. 12/12/2022 Implemented
2380.91(a)Repeat .91a- Individual #1's DOA was 7/1/22, fire training conducted 7/4/22 per the fire safety training form in the fire safety book, on 8/18/22 per the Assessment. The fire safety training was not held upon admission.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.This occurred due to the lack of management/ director in Adams County. Fire safety training will be incorporated into the admissions checklist to ensure that it is completed prior to the individual beginning in the program. This will be monitored by the Director of Adams County. TLC will review all individual's charts to ensure that they have been trained on Fire Safety upon admission. This audit will be completed by 12/21/2022. 12/21/2022 Implemented
2380.111(c)(1)The 5/27/22 physical examination does not include a review of Individual #1's previous medical history.The physical examination shall include: A review of previous medical history.All annual physicals for day program individuals will be audited to ensure all fields have been completed during the exam. If there are missing components, staff will contact the physician and amendments will be made as necessary by 12/21/2022. 12/21/2022 Implemented
2380.173(1)(ii)Individual #1's record does not indicate eye or hair color.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The individuals face sheet was updated immediately. This occurred due to lack of monitoring of the face sheet information, and lack of information upon admission. The Director of Operations is currently auditing all face sheets for all regulatory requirements. All face sheets with missing information or errors will be corrected by 12/21/2022. 12/21/2022 Implemented
2380.181(a)(Repeat from the January 2022 inspection) Individual #1's DOA was 7/1/22, the initial Assessment was not completed until 9/28/22. This exceeded the 60 calendar days after admission.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.This occurred due to the lack of management/ director involvement. TLC is hiring a Director of Adams County to oversee the program to ensure that the regulatory requirements are being met. TLC will audit all annual assessments to ensure that they have been completed, signed, and dated upon admission by 12/21/2022. 12/21/2022 Implemented
2380.21(u)REPEAT from inspection January 2022- - Individual #1's Date of Admission (DOA) was 7/1/22, the agency did not inform Individual #1 of the Rights upon admission, the rights were reviewed on 8/18/22. Individual #1 & #2 were not given the 2380 Rights to review. The agency reviewed the 6400 Rights with the Individuals.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.TLC will complete an audit of the day program individuals to ensure each individual had their rights reviewed with them upon admission. This audit will be completed by 12/21/2022. 12/21/2022 Implemented
2380.181(f)Individual #2 annual assessment 3/2/22 was not sent to the plan team members.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.This occurred due to the lack of management/ director involvement. TLC is hiring a Director of Adams County to oversee the program to ensure that the regulatory requirements are being met. TLC will be auditing all annual assessments to ensure that there is record of the assessment being sent to the team by 12/21/2022. TLC plans to hire a Director by 1/16/2023. 12/21/2022 Implemented
SIN-00198990 Renewal 01/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(a)The first aid area for the program is located in a room that is utilized as a storage area and common area for all individuals. There is no partition or privacy screen separating the area from the program area.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.TLC was unaware of the requirement for the partition. TLC is ordering a partition to put in the first aid room immediately. 02/04/2022 Implemented
2380.111(c)(5)Individual #2 had a tuberculin test completed on 5/17/19 and not again until 6/5/21.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.In this particular circumstance, individual was not in the program during the time of the appointment and parents opted to not get the individual their TB skin test. 02/04/2022 Implemented
2380.111(c)(10)(REPEAT VIOLATION FROM 1/28/21)- The medical information pertinent to diagnosis or treatment section on Individual #2's 6/4/21 annual physical examination was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.This occurred due to staff not being trained on medical appointments, and the required documentation, nor was the forms being monitored following appointments. Staff will be retrained on medical appointments and requirements including printing medical appointment form prior to appointment, taking the form along, ensuring the form is completed and signed my licensed medical professional (not CRNP or nurse). QD will go through records to determine dates of all individual's annual physicals and will contact appropriate management to schedule the appointment (PS, PM). Physicals will be scheduled in advance to ensure completion. 02/04/2022 Implemented
2380.115(1)(REPEAT VIOLATION FROM 1/28/21) -- Individual #1 and Individual #2's emergency medical plan, dated 1/4/22, indicates that York Hospital is the hospital or source of health care to be used in an emergency. Typical Life Corporation Gettysburg is not located in York.The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency.This occurred due to staff pulling the incorrect day program information. The hospital information is correct. 02/04/2022 Implemented
2380.171(b)(1)At the time of the 1/25/22 inspection, the emergency contact listed for Individual #1 was a former employee of Typical Life Corporation, who has not been employed by the agency since 10/2021.Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.This occurred due to the face sheet not being updated or monitored. This information has not been updated. 02/04/2022 Implemented
2380.181(a)(REPEAT VIOLATION FROM 1/28/21) -- Individual #1's date of admission to Typical Life Corporation Gettysburg is 7/21/21. Their initial assessment was not completed, signed, and dated by the program specialist until 12/21/21. Individual #2's assessment was done on 10/2/19 and not again until 10/21/21. This assessment should have been completed no later than 6/30/21 per the ODP announcement 21-016.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.This occurred because there has been a significant turnaround in Program Specialists and a lack of training/ supervision. Program Specialists will be retrained on annual assessment requirements per the 6400 regulations. Intermittently, Quality contacted the Program Specialist of each individual who needs an updated assessment as well as the Director of Residential Services. 02/04/2022 Implemented
2380.36(c)There are no records maintained that staff person #2 was trained in first aid before 1/17/22. Staff person #2's date of hire was 5/23/16. There are no records maintained that staff person #3 was trained in CPR and First Aid before 1/17/22. Staff person #3's date of hire was 5/6/20.There shall be at least 1 staff person for every 18 individuals, with a minimum of 2 staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.This has occurred due to staff not recording and maintaining training records. TLC has addressed this immediately and will begin to keep track of all training records per regulations. 02/04/2022 Implemented
SIN-00182111 Renewal 01/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The hot water temperature registered at 125 degrees.Hot water temperatures in areas accessible to individuals may not exceed 120°F.1) Maintaining safe water temperatures ensures that persons in care do not harm themselves if unable to independently temper their water. 1) The water temperature was fluctuating at 125 degrees after being increased for being at 111 degrees earlier in the morning. 1) The Director of Services checked the temperature that morning and noted it being 111. 2) There was a misunderstanding of regulation not realizing the window of acceptable temperature was between 100-120 not to drop below or above this identified range. 1) The Director had the GARA maintenance staff immediately temper down to be within the temp requirement of 100-120 degrees1) The Director of Services will review and train the water temperature regulation 2380.59 with the Program Specialist by. The Program Specialist will be trained by 2/28/2021. The Program Specialist will be responsible for monitioring the water temperature within the GARA building on a monthly basis. The temps will be checked monthly by the 15th of each month. When montitoring the temps the water must be between 100-120 degrees. If the temperature deviates from this the water will immediately be tempered accordingly by the GARA maintenance department. 02/28/2021 Implemented
2380.89(a)No fire drills occurred from August 2019 to November 2019.An unannounced fire drill shall be held at least once a month.1) Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. 1)A fire drill was not conducted as regulation states is required on a monthly basis (August 2019-November 2019)1) Documentation was not maintained adequately for the completed fire drills and was unable to be provided at time of request. 1) As part of the fire drill monitoring form this requirement is now clearly stated so staff conducting the fire drill know they must complete a monthly fire drill ensuring different days/times and routes are used. 2) This requirment will also be monitored on the fire drill log. 1) The Director of Compliance will update the Practice and Guideline 01-10000-0002 Fire Drills and the Directors of Service will provide training to the Program Specialist by 2/28/2021 to ensure competency with all FIre Drill regulations and parctices. Within this training the Program Specialist will become familiar with the fire safety and evacaution training plan. All staff will be trained in the regulation and its importance upon hire and reopening of the day program. 2) The Program Specialist of each Day Program will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each Day Program and their performance along on at least a monthly basis. A notification will be sent to any of the 3 day programs on the nearest business day to the 15th of the month if a fire drill entry has not happened at a program. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the Program Specialist and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. 02/28/2021 Implemented
2380.89(g)The fire drills for June 2019, July 2019, and March 2020 do not specify if all of the individuals met at the designated meeting place for each drill.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.1) Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. 1) The people we support did not make it to the designated location.1) Two of the three identified fire drills occurred prior to the new management was overseeing the Day Program (New Management began within the program MId December 2019). 2) Fire Drills were completed but documentation was not thoroughly idenifying that the persons made it to the designated location for the completed fire drills.1) The Directorof Services had columns added to the Fire Drill Log on 2/1/2021 for staff to indicate if they made it to the designated location and which location was used during the drill. 2) Upon reopening of the day programs all staff will be retrained on the fire safety training and evacuation plan to ensure competency 1) The Director of Compliance will update the Practice and Guideline 01-10000-0002 Fire Drills and the Directors of Service will provide training to the Program Specialist by 2/28/2021 to ensure competency with all FIre Drill regulations and parctices. Within this training the Program Specialist will become familiar with the fire safety and evacaution training plan. All staff will be trained in the regulation and its importance upon hire and reopening of the day program. 2) The Program Specialist of each Day Program will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each Day Program and their performance along on at least a monthly basis. A notification will be sent to any of the 3 day programs on the nearest business day to the 15th of the month if a fire drill entry has not happened at a program. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the Program Specialist and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. 02/28/2021 Implemented
2380.91(a)Individual #2 had fire safety training on 3/6/20. His first day at the program was 3/4/20. Fire safety training should have occurred on 3/4/20.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, 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.1) Fire safety training supports those in supports with knowing how to respond in the event that a fire would occur within the program. 1) A person in supports was not provided fire safety training on the day that they began in the program. 1) Despite training the ADOS responsible for this task did not ensure that the fire safety and evacuation training was completed on the first day in supports before participating in the fire drill. 1) This leader is no longer with the agency. 2) Retraining has been completed with the Program Specialist who will be overseeing the program once the reopening occurs by the Director of Services. 3) The Director of Service and Program Specialist are maintaining a checklist of items that need to be updated on the reopening date of program to ensure that all fire safety training refreshers are completed with the Direct Support Staff. 1) 1) The Director will train the Program Specialist and the Program Specialist will train the DSPs in the importance of regulation. All staff will be trainied in the regulation and its importance upon hire and reopening of the day program. 2) The Director of Services will be developing a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) The checklist will be revisited by the Program Specialist and will assist in maintaining all required documentation on and annual basis. 5) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.111(c)(4)The most recent physical for Individual #1 dated 7/23/19 did not address if she had her hearing or vision screened.The physical examination shall include: Vision and hearing screening, as recommended by the physician.1) It is important for the person in supports to have these assessments completed to ensure in the event of an emergency that they do not need additional supports or assistive devices in place to help in maintaining their safety or aid in daily functioning needs. 1) A person in supports did not have their vision and hearing assessment documented on their physical form1) New leadership took over in the Day Program in December 2019. 2) The person in supports physical discrepancies were identified and planned to be reviewed at the next physical due date which was scheduled for July 2019. 3) The Day program was shutdown in March 2019 prior to this request being able to be completed by the family. 1) Currently the program is closed due to COVID. 2) Upon reopening, the person in supports will not be able to return to services without providing a new fully completed TLC physical in which all necessary components are thoroughly filled out. 3) Once a date is established the physicals will be sent via mail/email to the families to ensure new physicals filled out correctly can be collected before readmission to the program. 1) The program specialist will only accept TLC physicals and will not permit the persons to return to program without the physical filled out in full. 2) The physicals will be collected prior to return or when starting the program and will need to be maintained thereafter on an annual basis on a TLC form and thoroughly documented. 2)The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) A practice and guideline will be developed by the Director of Service to ensure that the Program Specialist and DSPs have a point of reference to help guide the use of the checklist. 5) The Program Specialist will complete the checklist items annually by entering the new dates in the quicklook spreadsheet 7 ) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 8) The Director of Services will complete a training with the Program Specialist to include training on the Practice and guideline, completing the checklist, and how to maintain the quicklooks. 02/28/2021 Implemented
2380.111(c)(6)The most recent physical for Individual #1 dated 7/23/19 did not address if she was clear of communicable diseases.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.1) This is important as it mitigates the risk of communicable diseases being presented within the day program1) The Tuberculin Test was not documented on the annual physical form identifying when it was last completed 1) New leadership took over in the Day Program in December 2019. 2) The person in supports physical discrepancies were identified and planned to be reviewed at the next physical due date which was scheduled for July 2019. 3) The Day program was shutdown in March 2019 prior to this request being able to be completed by the family. 1) Currently the program is closed due to COVID. Upon reopening, the person in supports will not be able to return to services without providing a new fully completed TLC physical in which all necessary components are thoroughly filled out. 2) Once a date is established the physicals will be sent via mail/email to the families to ensure new physicals filled out correctly can be collected before readmission to the program. 1) The program specialist will only accept TLC physicals and will not permit the persons to return to program without the physical filled out in full. 2) The physicals will be collected prior to return or when starting the program and will need to be maintained thereafter on an annual basis on a TLC form and thoroughly documented. 2)The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) A practice and guideline will be developed by the Director of Service to ensure that the Program Specialist and DSPs have a point of reference to help guide the use of the checklist. 5) The Program Specialist will complete the checklist items annually by entering the new dates in the quicklook spreadsheet 7 ) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.111(c)(7)The most recent physical for Individual #1 dated 7/23/19 did not address her health maintenance needs, medical regiment, or need for blood work.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.1) It is important to understand the medications that the persons are taking as well as any present medical needs to ensure staff know how to care or support them in the event of a medical emergency. 2) This form would assist in providing necessary info to a medical provider in the event of an emergent medical situation. 1) The individuals health assessment did not get filled out in full to include the health maintenance needs, medication regiment or need for bloodwork1) New leadership took over in the Day Program in December 2019. 2) The person in supports physical discrepancies were identified and planned to be reviewed at the next physical due date which was scheduled for July 2019. 3) The Day program was shutdown in March 2019 prior to this request being able to be completed by the family. 1) Currently the program is closed due to COVID. 2) Upon reopening, the person in supports will not be able to return to services without providing a new fully completed TLC physical in which all necessary components are thoroughly filled out. 3) Once a date is established the physicals will be sent via mail/email to the families to ensure new physicals filled out correctly can be collected before readmission to the program. 1) The program specialist will only accept TLC physicals and will not permit the persons to return to program without the physical filled out in full. 2) The physicals will be collected prior to return or when starting the program and will need to be maintained thereafter on an annual basis on a TLC form and thoroughly documented. 2)The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) A practice and guideline will be developed by the Director of Service to ensure that the Program Specialist and DSPs have a point of reference to help guide the use of the checklist. 5) The Program Specialist will complete the checklist items annually by entering the new dates in the quicklook spreadsheet 7 ) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.111(c)(8)The most recent physical for Individual #1 dated 7/23/19 did not address her physical limitations.The physical examination shall include: Physical limitations of the individual.1) Understanding someone's limitations supports staff in how they need to assist the person in supports and further understanding areas in which they can excel to ensure goals are obtainable 1) Limitations were not documented by the physician on a persons annual physical form. 1) New leadership took over in the Day Program in December 2019. 2) The person in supports physical discrepancies were identified and planned to be reviewed at the next physical due date which was scheduled for July 2019. 3) The Day program was shutdown in March 2019 prior to this request being able to be completed by the family. 1) Currently the program is closed due to COVID. 2) Upon reopening, the person in supports will not be able to return to services without providing a new fully completed TLC physical in which all necessary components are thoroughly filled out. 3) Once a date is established the physicals will be sent via mail/email to the families to ensure new physicals filled out correctly can be collected before readmission to the program. 1) The program specialist will only accept TLC physicals and will not permit the persons to return to program without the physical filled out in full. 2) The physicals will be collected prior to return or when starting the program and will need to be maintained thereafter on an annual basis on a TLC form and thoroughly documented. 2)The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) A practice and guideline will be developed by the Director of Service to ensure that the Program Specialist and DSPs have a point of reference to help guide the use of the checklist. 5) The Program Specialist will complete the checklist items annually by entering the new dates in the quicklook spreadsheet 7 ) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.111(c)(9)The most recent physical for Individual #1 dated 7/23/19 did not address her allergies or contraindicated medications.The physical examination shall include: Allergies or contraindicated medication.1) Knowing someone's allergies or contraindicated medications is essential to ensuring safety. 2) It allows staff to support the person in making health safety conscious decisions and understanding how to respond if the person comes in contact with identified allergy. 1) The annual physical form did not include the persons allergies or contraindicated medication.1) New leadership took over in the Day Program in December 2019. 2) The person in supports physical discrepancies were identified and planned to be reviewed at the next physical due date which was scheduled for July 2019. 3) The Day program was shutdown in March 2019 prior to this request being able to be completed by the family. 1) Currently the program is closed due to COVID. 2) Upon reopening, the person in supports will not be able to return to services without providing a new fully completed TLC physical in which all necessary components are thoroughly filled out. 3) Once a date is established the physicals will be sent via mail/email to the families to ensure new physicals filled out correctly can be collected before readmission to the program. 1) The program specialist will only accept TLC physicals and will not permit the persons to return to program without the physical filled out in full. 2) The physicals will be collected prior to return or when starting the program and will need to be maintained thereafter on an annual basis on a TLC form and thoroughly documented. 2)The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) A practice and guideline will be developed by the Director of Service to ensure that the Program Specialist and DSPs have a point of reference to help guide the use of the checklist. 5) The Program Specialist will complete the checklist items annually by entering the new dates in the quicklook spreadsheet 7 ) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.111(c)(10)The most recent physical for Individual #1 dated 7/23/19 did not address her information pertinent to diagnose/treat in the event of an emergency. Individual #2's most recent physical dated 2/12/20 left this section blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Having diagnosis and treatment information is important in the event of an emergency as it allows emergency works a clear understanding of how best to support the person and potential risks or concerns relevant to their needs. The annual physical form submitted was not a TLC form. The physician did not complete the medical information pertinent to the diagnosis and treatment in case of an emergency. New leadership took over in the Day Program in December 2019. The person in supports physical discrepancies were identified and planned to be reviewed at the next physical due date which was scheduled for July 2019. The Day program was shutdown in March 2019 prior to this request being able to be completed by the family. Currently the program is closed due to COVID. Upon reopening, the person in supports will not be able to return to services without providing a new fully completed TLC physical in which all necessary components are thoroughly filled out. Once a date is established the physicals will be sent via mail/email to the families to ensure new physicals filled out correctly can be collected before readmission to the program. 1) The program specialist will only accept TLC physicals and will not permit the persons to return to program without the physical filled out in full. 2) The physicals will be collected prior to return or when starting the program and will need to be maintained thereafter on an annual basis on a TLC form and thoroughly documented. 2)The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) A practice and guideline will be developed by the Director of Service to ensure that the Program Specialist and DSPs have a point of reference to help guide the use of the checklist. 5) The Program Specialist will complete the checklist items annually by entering the new dates in the quicklook spreadsheet 7 ) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.115(1)The facility did not have an emergency medical plan for Individual #2 addressing which hospital to take the individual to in the event of a medical emergency.The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency.1) The Emergency Medical Plan would ensure that staff working with the person in care would know what to do, where to go and how to plan in the event of an emergent situation. 1) An emergency medical plan was not completed for a person in support during there initial week in services. 2) This person attended program 2 scheduled days prior to the program being closed for COVID. 1) Those new to TLC in the leadership position were not familiar with this regulation until after the program had closed and the opportunity to complete the task was unavailable. 1) The Program Specialist will ensure that the Emergency Medical Plan is completed on the first day of reopening of the program to identify which hospital the the person should be brought to in the event of a medical emergency. 1) The Program Specialist will be responsible to ensure that all DSPs complete the retraining for fire safety and evacuation training prior to the reopening of the program. 2) The Director of Services will be developing a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) The checklist will be revisited by the Program Specialist and will assist in maintaining all required documentation on and annual basis. 5) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.115(2)The facility did not have an emergency medical plan for Individual #2 addressing the transportation used to take the individual to in the event of a medical emergency.The facility shall have a written emergency medical plan listing the following: The method of transportation to be used.1) The Emergency Medical Plan would ensure that staff working with the person in care would know what to do, where to go and how to plan in the event of an emergent situation. 1) An emergency medical plan was not completed for a person in support during there intial week in services. 2) This person attended program 2 scheduled days prior to the program being closed for COVID. 1) Those new to TLC in the leadership position were not familiar with this regulation until after the program had closed and the opportunity to complete the task was uavailable. 1) The Program Specialist will ensure that the Emergency Medical Plan is completed on the first day of reopening of the program to identify how to transport the person in services to the hospital in the event of a medical emergency. 1) The Program Specialist will be responsible to ensure that all DSPs complete the retraining for fire safety and evacuation training prior to the reopening of the program. 2) The Director of Services will be developing a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) The checklist will be revisited by the Program Specialist and will assist in maintaining all required documentation on and annual basis. 5) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.115(3)The facility did not have an emergency medical plan for Individual #2 addressing emergency medical staffing in the event of a medical emergency.The facility shall have a written emergency medical plan listing the following: An emergency staffing plan.1) The Emergency Medical Plan would ensure that staff working with the person in care would know what to do, where to go and how to plan in the event of an emergent situation. 1) An emergency medical plan was not completed for a person in support during there initial week in services. 2) This person attended program 2 scheduled days prior to the program being closed for COVID. 1) Those new to TLC in the leadership position were not familiar with this regulation until after the program had closed and the opportunity to complete the task was unavailable. 1) The Program Specialist will ensure that the Emergency Medical Plan is completed on the first day of reopening of the program to identify an emergency staffing plan in the event of a medical emergency. 1) The Program Specialist will be responsible to ensure that all DSPs complete the retraining for fire safety and evacuation training prior to the reopening of the program. 2) The Director of Services will be developing a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) The checklist will be revisited by the Program Specialist and will assist in maintaining all required documentation on and annual basis. 5) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.173(1)(v)Individual #2 did not have a current and dated photograph in the record.Each individual's record must include the following information: Personal information including: A current, dated photograph.1) It is important to maintain demographic information and a current photo as it is needs to be accurate to support in the event of an emergency 1) A current photo was not on file for a person in supports 1) The person in supports started one week prior to the COVID pandemic starting. 2) The photo was not taken on their initial two days in service.1) The Director of Service and Program Specialist are maintaining a checklist of items that need to be updated on the reopening date of program to ensure that all photo requirements are met within the annual time frame. 1) A new admission checklist was developed by the Director of Services to ensure that all requirements are listed for persons starting services. 2) This checklist will be implemented by the program specialist and completed on the first day in service to ensure that all requirements are met. 3) The checklist will be revisited by the program specialist and will assist in maintaining all required documentation on and annual basis. 4) The quicklooks documentation will support the Program Specialist in maintaining the documentation requirements. 5) in addition to the photos taken on their start date the photos will also be taken annually for all persons in May. 02/28/2021 Implemented
2380.177No release of information was provided for either Individual #1 or Individual #2.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.1) A medical release ensures that needed information will be able to be released to aide in the care of the person in supports.1) Generic emergency releases were not on file in the event that an emergent situation arose and the safety of person in support was compromised. 1) The regulation was not interpreted by TLC to determine that a generic release would be needed to maintain the care of the person in supports. 1) The Directors of service will develop a generic emergency release and implement the form in the AWARDS system to ensure compliance once the programs reopen. 1) The Directors of Service for York and Adams County will develop an emergency release form that will be completed by 2/28/2021. 2) Once the day program reopen the form will be completed by all day program participants. 02/28/2021 Implemented
2380.181(a)Individual #1 had an assessment completed 1/7/19 and not again until 1/9/21. Assessments are to be completed annually and should have been completed in January 2020, prior to Covid.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.1) The assessment supports in identifying progress/regressions made in services and how best to support the person moving forward. 2) It is a document that allows for new staff to get to better familiarize themselves with the person they will be working within the provided services. 1) An annual assessment was not completed for January 2020. 1) New leadership took over in the Day Program in December 2019. 2) Those in the new leadership were still learning their responsibilities and were unaware of timelines and upcoming due dates at the time identified. 1) The Director of Services developed and implemented a quick looks spreadsheet that breaks down when the quarterly and annual assessments are due to ensure that there is clarity of upcoming due dates. 2) The Program Specialist was trained on 12/31/2020 on how to use this document and has already implemented the tool into their daily functions. 1 . Upon intake, the Program Specialist will add the new admission into the quicklooks document. 2) The program specialist will be expected to maintain the quicklooks to include all ISP and Quarterly dates. The program specialist has reached out to the Supports Coordinators to request all Annual ISP and quarterly dates for persons in care be submitted in letter form one year out to ensure adequate planning and opportunity to complete necessary assessments. 3) The due dates for current participant quarterlies have been entered on the Quicklook spread sheet as well as the day program calendar which both the Program Specialist and Director have access to. 4) The Director has instructed the Program Specialist that an invite will be sent to include the director in all Annual ISP meetings to oversee completion of all requirements. The Program Specialist will be in contact with all SCs by 2/28/2021 and a collateral note will be entered into awards demonstrating all efforts. 02/28/2021 Implemented
2380.21(u)No individual rights were in the record for either Individual #1 or Individual #2.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.1) Routinely advising the person of their individual rights protects them from any purposeful acts to remove or withhold their protected rights.1) The persons in support all reviewed the Individual Rights with the Director of Services. 2) The documentation was given to the ADOS who was tasked to scan it into the AWARDS system but these documents were not able to produced when requested. 1) Individual Rights were reviewed in person and signatures were collected on paper. 2) The signed documents were not scanned into the electronic chart as directed. 3) The documentation was unable to be located when requested. 1) The Director of Service developed a quick look spreadsheet identifying dates that documentation is to be completed in the electronic AWARDS system. 2) On opening day of the day program these documents will be completed and documented on the spreadsheet to ensure the date is maintained along with the electronic signed rights. 1) The Program Specialist will be responsible to ensure that all DSPs complete the retraining for the annual individual rights. 2.) The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) The checklist will be revisited by the Program Specialist and will assist in maintaining all required documentation on and annual basis. 5) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
2380.21(v)No signed statement of individual rights was in the record for either Individual #1 or Individual #2.The facility shall keep a copy of the statement signed by the individual or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.1) Routinely advising the person of their individual rights protects them from any purposeful acts to remove or withhold their protected rights.1) The persons in support all signed a copy of the individual rights after reviewing the documentation with the Director of Services. 2) The documentation was given to the ADOS who was tasked to scan it into the AWARDS system but these documents were not able to produced when requested. 1) Individual Rights were reviewed in person and signatures were collected on paper. 2) The signed documents were not scanned into the electronic chart as directed. 3) The documentation was unable to be located when requested. 1) The Director of Service developed a quick look spreadsheet identifying dates that documentation is to be completed in the electronic AWARDS system. 2) On opening day of the day program these documents will be completed and documented on the spreadsheet to ensure the date is maintained along with the electronic signed rights. 1) The Program Specialist will be responsible to ensure that all DSPs complete the retraining for the annual individual rights. 2.) The Director of Services developed a new admission checklist to ensure that all requirements are listed for persons starting services. 3) This checklist will be implemented by the Program Specialist and completed on the first day of service to ensure that all requirements are met. 4) The checklist will be revisited by the Program Specialist and will assist in maintaining all required documentation on and annual basis. 5) The quicklooks documentation will support the Program Specialist in maintaining the documentation deadlines. 02/28/2021 Implemented
SIN-00136044 Renewal 07/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #2 had fire safety training on 5/8/2017 and none since.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Staff #2 was trained was trained on TLC Compliance training Part 1 and Part 2 on 4/30/2018 through the College of Direct Supports. TLC Compliance training consists of OSHA, Fire Safety and Billing. See Attachment #36 Page 1 and Page 2. The attachment is the transcripts for staff #2 showing she had the fire safety training on 4/30/2018. 04/30/2018 Implemented
2380.89(c)The 1/23/2018 fire drill record did not include the amount of time it took for evacuation or the exit route used. The 7/19/17 fire drill log did not document whether the fire alarm was operative.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 was operative.All Day Programs within Typical Life Corporation are now required to use the electronic Google Fire Drill Form that is currently being used in the Residential Programs. This Google Form has required sections which include the amount of time it took for evacuation or the exit route used and a required section for whether the fire alarm was operative. These sections must be completed or the Google Fire Drill Form will not allow you complete the Fire Drill until these sections are completed. The Director of Quality and Associate Director of Quality electronically receive the fire drills so they can be reviewed for accuracy. See Attachment # 2380.89. 07/26/2018 Implemented
2380.89(g)The 1/23/2018 fire drill log did not indicate if the individuals evacuated to the designated meeting place.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.All Day Programs within Typical Life Corporation are now required to use the electronic Google Fire Drill Form that is currently being used in the Residential Programs. This Google Form has required sections which include: Describing the exact evacuation route for each individual to evacuate the area. The google form also requires a section as to whether or not all individuals made it to the designated meeting place during each fire drill. These sections must be completed or the Google Fire Drill Form will not allow you complete the Fire Drill until these sections are completed. The Director of Quality and Associate Director of Quality electronically receive the fire drills so they can be reviewed for accuracy. See Attachment # 2380.89. 07/26/2018 Implemented
2380.89(h)The fire drill logs for drills held on 11/21/2017, 10/20/2017, 8/24/2017, and 7/19/2017 did not include whether an alarm was set off.A fire alarm shall be set off during each fire drill.All Day Programs within Typical Life Corporation are now required to use the electronic Google Fire Drill Form that is currently being used in the Residential Programs. This Google Form has required sections which include: Was the smoke detector set off during the fire drill. These sections must be completed or the Google Fire Drill Form will not allow you complete the Fire Drill until these sections are completed. The Director of Quality and Associate Director of Quality electronically receive the fire drills so they can be reviewed for accuracy. See Attachment # 2380.89. 07/26/2018 Implemented
2380.173(9)Individual #1's ISP documents seasonal allergies as a diagnosis. Physical completed on 12/15/2017 did not indicate seasonal allergies.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program Specialist will use a physical form that was created on Awards, which is the electronic health records data collection system used at TLC. The Physical Form is pre-populated from information maintained within the AWARDS System. The allergies or contraindicated medications are pulled from the allergy section and contraindicated section within AWARDS which is then pre-populated on to the Individual¿s Physical form. See attachment 173(9) Page 1,2 and 3. 07/26/2018 Implemented
2380.183(5)Individual #1 and Individual #2's ISPs did not include the following: A protocol to address the social, emotional and environmental needs of the individual.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Program Specialist will email the Supports Coordinator a SEEN Plan for each individual with a SEEN Plan.See Attachment 183(5) Pages 1-5. At each annual review, the Supports Coordinator will be given a SEEN plan to be reviewed and submitted into the ISP. See Attachment 186(b) ISP Review (Quarterly) Checklist which requires a SEEN plan to be completed if applicable. 08/01/2018 Implemented
2380.186(b)Individual #1's 12/27/2017 ISP review was not signed or dated by the Individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.An ISP Review (Quarterly) Checklist has been implemented to ensure all aspects of ISP Review are completed accurately. This ISP Review Checklist includes that the ISP 3 month review has been signed by the Program Specialist and the Individual. The Program Specialist will sign off on the Checklist after reviewing the Checklist. The Checklist will then be retained by the Appropriate ADOS (associate Director of Services). See Attachment #186(b) Page 1 and Page 2. 07/27/2018 Implemented
2380.186(e)Individual #2's record did not include documentation that team members were given the option to decline the ISP review documentation.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Program Specialist will use a letter, for all individuals, generated within AWARDS,which is the electronic health records data collection system used at TLC. This ISP Review Letter (Gettysburg) has a sentence that states the following: ¿If you wish to no longer receive ISP Reviews and updates, please document that in writing to me at 545 Long Lane Gettysburg, PA 17325. Contact phone number and email address are listed below¿. See attachment Page 1 186(e). 07/16/2018 Implemented
SIN-00115934 Renewal 06/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1 and Staff #2 completed annual fire safety training on 6/1/17 and 5/30/17, respectively. The fire safety training was an online training and was not produced by a fire safety expert.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Program Specialist will contact Gettysburg Fire Department to set up an annual training with fire safety experts. If Gettysburg Fire Department is unable to do annual training, staff will be trained annual Fire School completed by East York Fire Department. 06/30/2017 Implemented
2380.89(a)Staff #1 used the alarm panel to set off the alarm system in the building. Upon opening the panel, the system stated to the building that the alarm panel was open alerting staff and individuals that a drill was about to occur. The staff and individuals present during inspection were outside the building before the fire alarm sounded. An unannounced fire drill shall be held at least once a month.The smoke detector in the TLC office will be set off by smoke from a can. The smoke detector in the office is out of the programming area and will not be able to be seen by staff or individuals when set off during fire drills. 06/27/2017 Implemented
2380.111(c)(4)Individual #1's 12/14/16 physical exam did not include a vision and hearing screening. The exam did not contain a vision and hearing section for the physician to respond to.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #1's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #13 and #14 to reflect Individual#1's correct vision and hearing. An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111 Addendum. Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.111(c)(5)Individual #1's 12/14/16 physical exam did not include the date the tuberculin test was read or the results of the test. 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.Individual #1's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #4 to include Individual#1's date of tuberculin test when it was read or the results of the test. . An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111 Addendum. Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.111(c)(6)Individual #1's 12/14/16 physical exam did not include his/her communicable disease status.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.Individual #1's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #17 to include if Individual#1's has any Specific precautions that shall be taken if the individual has a serious communicable disease. An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111 Addendum. Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.111(c)(7)Individual #1's 12/14/16 physical exam did not include health maintenance needs, medication regimen, and the need for blood work. 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.Individual #1's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #2 to include current medication regimen, section #15 any recommendations for blood work and section #16 if there are any health maintenance needs. An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111 Addendum. Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.111(c)(8)Individual #1's 12/14/16 and Individual #2's 2/2/17 physical exam did not include physical limitations.The physical examination shall include: Physical limitations of the individual.Individual #1's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #23 to Orthopedic Limitations/Physical Limitations (physical joint abnormalities). An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111 Addendum. Individual #2's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #23 to Orthopedic Limitations/Physical Limitations (physical joint abnormalities). An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111(c)(8) Addendum Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.111(c)(9)Individual #1's 12/14/16 physical exam did not include allergies.The physical examination shall include: Allergies or contraindicated medication.Individual #1's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #6 to include Allergies or contraindicated medication. An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111 Addendum. Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.111(c)(10)Individual #1's 12/14/16 physical exam did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #1's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #5 to include Medical information pertinent to diagnosis and treatment in case of an emergency. An Addendum has been added to Individual #1's Physical Form until Doctor return's updated Physical . Attachment #111 Addendum. Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.111(c)(11)Individual #2's 2/2/17 physical exam did not include diet instructions. The physical exam did not contain a space for the physician to respond to.The physical examination shall include: Special instructions for an individual's diet.Individual #2's Physical will be sent back to doctor by 6/30/2017. Typical Life will ask for corrections to be made on the Physical Form, section #9 to include Special Dietary Instruction. An Addendum has been added to Individual #2's Physical Form until Doctor return's updated Physical . Attachment #111(c)(8) Addendum. Moving forward All participants will be given TLC Physical Form for annual physicals and physicals prior to starting the program. TLC Physical Checklist will be completed to ensure all portions of the physical have been properly completed. 06/30/2017 Implemented
2380.177Consent to release information to Individual #2's team members was not completed. Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.Per Typical Life Policy 0200-024 Resident Rights, Information for Release and Media Release forms are all to updated at the Individual's Annual ISP Review. Residential Program Specialists were following, however Day Program Program Specialists were not. Moving forward Day Program, Progam Specialists will be following the Policy 0200-024. Day Program Specialists were notified by email on 6/27/2017 to begin following this Policy as of 6/27/2017. See Attachment# 177 Email sent to Day Program Program Specialist 06/27/2017 Implemented
2380.181(a)Individual #1 was admitted to the program on 2/15/17. The initial assessment was not completed until 5/3/17. Individual #2 was admitted to the program on 7/18/16. The initial assessment was not completed until 9/30/16.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 Day Program Assessment Checklist was revised on 3/13/2017 to include the following statement: ** Assessments must be completed 1 year prior to or 60 calendar days after admission and updated annually thereafter". See attachment 2380.181(a). The Day Program Assessment Checklist was revised on 6/26/2017 to include the following statement: Cover Sheet must be Signed/Dated upon completion. Must be completed within appropriate time frame. Program Specialist can sign before reviewing with Individual. Reviewed and signed by Individual. See Attachment 181(a) Assessment Checklist Page 1, Page 2 and Page 3. 06/27/2017 Implemented
2380.181(e)(5)Individual #1's 5/3/17 assessment did not include his/her ability to self-administer medications.The assessment must include the following information: The individual¿s ability to self-administer medications.An addendum to Individual #1's assessment was completed to include in the assessment the individual's ability to self-administer medications. See Attachment 181(e)(5) Page 1 and Page 2 Addendum. A copy was e-mailed to the Supports Coordinator. See Attachment 181(e)(5) Email to Supports Coordinator. The Day Program Checklist was revisesd on 6/27/17 under VII Self-Administration that reads-still include if medications are not given at day program. See Attachment 181(e)(5) Revised Assessment Checklist dated 6/26/2017. 06/26/2017 Implemented
2380.181(e)(7)Individual #1's 5/3/17 assessment and Individual #2's 9/30/16 assessment did not include his/her ability to move away from heat sources. The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The Day Program Assessment Checklist was revised on 6/26/2017 to include the following statement: Under Section IX:Heat Sources-must show ability to move away from heat sources. See Attachment 181(e)(5) Revised Assessment Checklist dated 6/26/2017. Addendum was made to Individual #1's 5/3/17 assessment See Attachment 181(e)(5) Page 1 and Page 2 Addendum. A copy was e-mailed to the Supports Coordinator. See Attachment 181(e)(5) Email to Supports Coordinator. Addendum was made to Individual #2's 9/30/16 assessment to include his/her ability to move away from heat sources. See Attachments 181(e)(7) Page 1 and Page 2. A copy was e-mailed to the Supports Coordinator. See Attachment 181(e)(7) Email to Supports Coordinator. The Day Program Checklist was revisesd on 6/27/17 under Section IX Heat Sources-must show ability to move away from heat sources. See Attachment 181(e)(5) Revised Assessment Checklist dated 6/26/2017. 06/26/2017 Implemented
2380.181(e)(10)Individual #2's 9/30/16 assessment indicated the lifetime medical history was attached. The lifetime medical history was completed on 3/10/17 and was not sent to plan team members with the assessment. The assessment must include the following information: A lifetime medical history.The Day Program Assessment Checklist was revised on 6/2717 to include the following statement: Lifetime Medical History Attached. See Attachment 181(e)(5) Revised Assessment Checklist dated 6/26/2017. A copy of the Lifetime Medical History was e-mailed to the Supports Coordinator. See Attachment 181(e)(10) Email to Supports Coordinator. 06/27/2017 Implemented
2380.181(f)There was no documentation to show Individual #1's 5/3/17 assessment was sent to plan team members.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).A copy of the 60 Day Assessment was e-mailed to the Supports Coordinator. See Attachment 181(e)(10) Email to Supports Coordinator. The Day Program Assessment Checklist was revised on 6/26/17 to include the following statement: Date Sent to Team. See Attachment 181(e)(5) Revised Assessment Checklist dated 6/26/2017. 06/27/2017 Implemented
2380.183(5)Individual #1's Individual Support Plan did not include a social, emotional, environmental needs plan. Individual #1 takes medication to treat anxiety. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.An Addendum to Individual #1's Individual Support Plan has been made an now include's a social, emotional, environmental needs plan. See Attachment#183(5). See Attachment#183(5) Page1, Page 2 and Page 3. See Attachment #183(5) Addendum Email sent Supports Coordinator. The ISP Checklist has been updated to reflect the following: Social/Emotional Information This section applies to all individuals that are diagnosed with a mental health disorder and are taking Psychotropic Medications. See Attachment #183(5) updated ISP Checklist Page 1 and Page 2. 06/27/2017 Implemented
2380.183(7)(i)Individual #1's Individual Support Plan did not include his/her potential to advance in vocational programming.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: Vocational programming.An addendum to Individual #1's Individual Support Plan was created to include her potential to advance in vocational programming. See Attachment#183(5) Page1, Page 2 and Page 3. A copy of the Addendum was e-mailed to the Supports Coordinator. See Attachment #183(5) Addendum Email. The ISP Checklist dated 6/27/2017 states: "Potential to advance in vocational programming."See Attachment #183(5) updated ISP Checklist.Page 1 and Page 2. 06/27/2017 Implemented
2380.183(7)(iii)Individual #1's Individual Support Plan did not include his/her potential to advance in competitive 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.An addendum to Individual #1's Individual Support Plan was created to include her potential to advance in competitive employment. See Attachment. A copy was sent to the Supports Coordinator. See Attachment#183(5) Page1, Page 2 and Page 3. A copy of the Addendum was e-mailed to the Supports Coordinator. See Attachment #183(5) Addendum Email. The ISP Checklist dated 6/27/2017 states: Potential to advance in competitive community integrated employment. "See Attachment #183(5) updated ISP Checklist Page 1 and Page 2. 06/27/2017 Implemented
2380.184(a)(1)(iii)A direct care worker was not present at Individual #2's Individual Support Plan meeting.The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision).A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering a service to the individual.The reason a direct care worker was not present at Individual #2's Individual Support Plan meeting was due to having to keep individuals within their staffing ratio's. TLC-Gettysburg will change all Individual's ISP Meetings to TLC-Gettysburg Day Program Area. This will ensure a direct care worker will be able to attend future ISP Meetings. 06/27/2017 Implemented
2380.186(c)(1)Individual #2's 10/25/16, 1/24/17, and 4/24/17 Individual Support Plan (ISP) reviews did not include participation and progress toward the ISP outcome of skill development.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.Goal plans were created and will be implemented to show progress in skill development. As an individual completes a goal, new goals will be created to continue growth and progress in skill developement. See Attachment# 186(c)(1) Pages 1 and Pages 2. 07/01/2017 Implemented
2380.186(d)There was no documentation that Individual #1's 5/3/17 Individual Support Plan review was sent to plan team members. 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 meeting.Individual #1's 5/3/17 Individual Support Plan review has been sent to plan team members. See Attachment # 186(d) Page 1.See Attachment # 186(d) Page 2 Cover Letter for Individual #1's 1st ISP Review. The ISP Review Checklist has been updated to includes a section that states "ISP Review and Cover Letter must be sent to all that apply". This section includes: Individual, Parent/Guardian, Supports Coordinator, Residential Provider, TLC Residential, PM, HCH. See Attachment# 186(d) Page 3 and Page 4. 06/27/2017 Implemented
2380.186(e)An option to decline was not offered to Individual #1's or Individual #2's plan team members.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The ISP Review Checklist has been updated to includes a section that states: ISP Review and Cover Letter must be sent to all that apply- Cover Letter must include ¿Option to decline the ISP Review documentation¿ statement. 06/27/2017 Implemented
SIN-00154456 Renewal 07/11/2019 Compliant - Finalized
SIN-00097482 Initial review 07/13/2016 Compliant - Finalized