| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(d) | The fire drills conducted 10/25/22, 11/28/22 and 12/19/22 each have an evacuation time of 3 minutes. At the time the fire drills were held, the provider did not have an extended evacuation time. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | VNA Extended Care, Inc. ADLC contacted the Washington Township Fire Chief, Shane Smerkar, who evaluated the center and clients and extended the evacuation time for fire drills to 3 minutes due to the different barriers the center faces due to the population of clients the staff cares for at the center. Ther are physical barrier-clients that need to be transferred to wheelchairs and cognitive barriers such as the ability to understand what is going on at that moment during the fire drill. |
09/30/2023
| Implemented |
| 2380.91(a) | Individual #4, date of admission 12/1/22 has not completed fire safety training. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | The Director of ADLC will contact client #4's caregiver on the client's need to attend and participate in the ADLC's review of emergency fire and medical procedures monthly at the ADLC. This will prepare the client in the event of a real fire emergency. |
10/27/2023
| Implemented |
| 2380.111(c)(4) | Individual #3's annual physical examination, completed 11/21/2022, did not contain a vision screening. The physical stated that the individual is followed by the eye doctor; however, no vision screening was included in the record. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | The Director of ADLC will obtain (in coordination with UCIP) the client's vision and hearing screening to be included in the client's ADLC records. |
10/27/2023
| Implemented |
| 2380.111(c)(5) | Individual #1's most recently had a Tuberculin skin testing with negative results was completed 7/14/21. Individual #4's most recent tuberculin skin test via Mantoux method was completed on 3/18/2021. | 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. | The Director of ADLC will contact UCIP and/or client's physician if needed to obtain the TB skin testing results. |
10/27/2023
| Implemented |
| 2380.111(c)(6) | Individual #4's physical examination, completed on 9/14/2022, does not indicate if the individual is free of communicable diseases nor does it include specific precautions that shall be taken if the individual has a serious communicable disease. | 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. | The Director will work with client's caregiver and/or physician if needed to obtain this required portion of the regulation. |
08/25/2023
| Implemented |
| 2380.111(c)(8) | Individual #2's physical examination, completed on 9/14/2022, does not include physical limitations of the individual. The form did not include a section for this information. | The physical examination shall include: Physical limitations of the individual. | The Director of ADLC will obtain the client's physical limitations from UCIP and/or client's physician if needed to be in compliance with regulation 2380.111(c)(8). |
10/27/2023
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination completed 2/27/23, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #4's annual physical examination, completed on 9/14/2022, does not include medical information pertinent to diagnosis and treatment in case of emergency. The form did not include a section for this information. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Director will obtain from Individual #1's UCIP staff and/or the client's physician the medical information pertinent to diagnosis and treatment in case of an emergency. A record will be kept of the correspondence to obtain this data in the client's chart.
For individual #4 the Director will obtain the medical information from the client's caregiver and/or phsysician if needed, pertinent to diagnosis and treatment in case of an emergency. A record will kept of correspondence in the client's chart. |
10/27/2023
| Implemented |
| 2380.113(a) | Direct Service Worker #3, date of hire 2/28/22, had an initial physical examination completed 3/1/2022. Direct Services Worker #4 had a physical examination completed 10/21/19 and then again 11/24/21. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | A spreadsheet has been developed to track employees physical examnations to ensure regulary compliane with 2380.113 (a). |
10/27/2023
| Implemented |
| 2380.113(b) | Direct Service Worker #4's 11/24/21 physical examination was not completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | The program director will have Direct Service Worker #4 schedule a physical exam that will be dated and signed by a licensed physician, certified nurse practitioner or certified physician's assistant. |
10/02/2023
| Implemented |
| 2380.113(c)(2) | Direct Service Worker #3, date of hire 2/28/2023, had a Tuberculin skin testing with negative results completed 3/2/2022. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | Direct Service Worker #3 date of hire was 2/28/22. TB 2 step was initiated on 2/28/22. The 2nd step was completed on 3/14/22. VNA Extended Care, in compliance with regulation 2380.113(c)(2) will not permit Direct Care Workers to initiate direct client contact until 2nd TB test is read as negative. |
10/27/2023
| Implemented |
| 2380.173(1)(iv) | Individual #1's record did not include their religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | The ADLC Director will obtain Individual #1's religious affiliation from UCIP and/or client's family to be included in Client's Intake record. The INTAKE record was updated to include religious affiliation. |
08/25/2023
| Implemented |
| 2380.173(1)(v) | Individual #1 and Individual #4's records included photographs, however the photographs were not dated. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | The ADLC Director will update individual #1's and 4's photo and date the photos. |
08/25/2023
| Implemented |
| 2380.181(a) | Individual #1, #2, #3, and #4 did not have assessments. | 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 Director will provide an assessment for individual's 1, 2, 3, &4 to include all aspects of the regulatory requirement 2380.181(a). |
08/25/2023
| Implemented |
| 2380.21(u) | Individual #1, date of admission 12/4/17, was informed and explained individual rights 9/9/22. Documentation of reviewing individual rights during the 2021 calendar year was not provided, therefore compliance could not be measured. Individual #2, date of admission 12/13/22, was informed and explained individual rights 12/14/22. Individual #3, date of admission 4/3/08, was informed and explained individual rights 10/10/22. Documentation of reviewing individual rights during the 2021 calendar year was not provided, therefore compliance could not be measured. Individual #4's, date of admission 12/1/22, was informed and explained individual right 9/13/23. | 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. | The Director will review the invidual rights policy with the client and caregiver upon admission to the ADLC. This form will then be signed by the client and/or caregiver. |
10/27/2023
| Implemented |
| 2380.38(b)(3) | Direct Service Worke #3, date of hire 2/28/22 did not receive in training to in individual rights during orientation. | The orientation must encompass the following areas: Individual rights. | Direct Service Worker #3 will complete the individual rights training by 10/27/23. |
10/27/2023
| Implemented |
| 2380.39(a)(3) | Program Specialist #2, date of hire 6/6/19, completed 1 hour 21 minutes of training for training year 7/1/22 through 6/30/23. | The following shall complete 24 hours of training related to job skills and knowledge each year: Positions required by this chapter. | The program director will complete trainings to include: application of person-centerred practices, community integration, individual choice and supporting individuals to develop and maintain relationships, the prevention, detection adn reporting of abuse, suspected abuse and alledged abuse in accordance with OAPS, individual reights, recognizing and reporting incidents, the safe and appropriate use of behavior supports if the person works directly with an individual. These will be completed via the ODP website. |
09/30/2023
| Implemented |
| 2380.39(b)(1) | Chief Executive Officer #1, date of hire 4/4/94, completed 1.25 hours of training for training year 7/1/22-6/30/23. | The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | The CEO will complete the training to be in regulatory compliance of 2380.39(c)(1) by 9/30/23. |
09/30/2023
| Implemented |
| 2380.39(c)(1) | Chief Executive Officer #1, date of hire 4/4/94, and Program Specialist #2, date of hire 6/6/19, did not receive training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during training year 7/1/22 through 6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The CEO and the Program Specialist #2 will complete the training to be in regulatory compliance of 2380.39(c)(1) by 9/30/23. |
09/30/2023
| Implemented |
| 2380.39(c)(2) | Chief Executive Officer #1, date of hire 4/4/94, and Program Specialist #2, date of hire 6/6/19, did not receive training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during training year 7/1/22 through 6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | CEO and the program specialist will complete the required trainings as indicated in 2380.39(c)(2) by 9/30/23. Proof of completion will be submitted. |
09/30/2023
| Implemented |
| 2380.39(c)(3) | Chief Executive Officer #1, date of hire 4/4/94, and Program Specialist #2, date of hire 6/6/19, did not receive training in Individual rights during training year 7/1/22 through 6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | CEO and the program specialist will complete the required trainings as indicated in 2380.39(c)(2) by 9/30/23. Proof of training will be submitted. |
09/30/2023
| Implemented |
| 2380.39(c)(4) | Chief Executive Officer #1, date of hire 4/4/94, Program Specialist #2, date of hire 6/6/19, did not receive training in recognizing and reporting incidents during training year 7/1/22-6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | CEO and the program specialist will complete the required trainings as indicated in 2380.39(c)(4) by 9/30/23. Proof of completion will be submitted. |
09/30/2023
| Implemented |
| 2380.39(c)(5) | Program Specialist #2, date of hire 6/6/19, did not receive training in the safe and appropriate use of behavior supports in training year 7/1/22 through 6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | The program specialist will receive training on safe and appropriate use of behavior supports by 9/30/23 via ODP website training.Proof of training will be submitted. |
09/30/2023
| Implemented |
| 2380.39(c)(6) | Program Specialist #2, date of hire 6/6/19, did not receive training in implementation of the individual plan in training year 7/1/22 through 6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The program specialist will complete the training for implementation of the individual plan by 9/30/23. Proof of completion will be submitted. |
09/30/2023
| Implemented |
| 2380.122(b)(2) | Program Specialist #2 completed the Department of Human Services Medication Administration Train the Trainer Training on 4/14/2022. There was no documentation of initial med observations completed and the annual practicum was incomplete. Program Specialist #2 administered medications to Individual # 5 on June 1,5,7,21, and 28, 2023; July 12 and 17, 2023 and August 2, 7, and 9, 2023. Direct Service Worker #3 completed the Department of Human Services Modified Medication Administration Course 6/14/21. There is no documentation of any annual practicums being completed. Direct Service Worker #3 administered medications to Individual #5 on June 7.9.12.14.16.19.21.23.26.28 and 30, 2023, July 10, 14, 17, 25, 26, 28 and 31, 2023 and August 2, 4, 7, and 9, 2023. | A prescription medication that is not self-administered shall by one of the following: A person who has completed the medication administration course requirements as specified in § 2380.129 (relating to medication administration training) for the medication administration of the following: (i) Oral medications. (ii) Topical medications. (iii) Eye, nose and ear drop medications. (iv) Insulin injections. (v) Epinephrine injections for inspect bites or other allergies. | 2 of the ADLC program assistants will complete the medication administration training by 10/27/23. In the meantime, a RN or LPN will administer any required medications to ADLC clients. |
10/27/2023
| Implemented |
| 2380.125(f) | Individual #3's, date of admission 4/3/08, Social, Emotional, and Environmental Plan was last updated on 1/1/2018. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The ADLC Director will contact the client's program specialist to obtain the c-plan The program will include any correspondence with UCIP in the client's chart. |
10/27/2023
| Implemented |
| 2380.173(5) | Individual #1's record did not include a current Individual Support Plan. The Individual Support Plan in the record is dated 7/1/2022 -- 6/30/2023 fiscal year with an annual review update date of 7/22/2022. | Individual plan documents as required by this chapter. | The program director will print off a new ISP for the clients each quarter after their quarterly ISP meetings to ensure I have an up to date ISP for each individual. |
10/27/2023
| Implemented |