Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
2380.177 | Consent 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 |