Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.20(d) | Staff #2 was hired on 4/27/2016. A copy of her Criminal History Check is not in her file. | A copy of the final reports received from the State Police, and the FBI, if applicable, shall be kept. | Staff #2 criminal history check is now on file. |
01/05/2018
| Implemented |
2380.36(c) | Brass Castle does not have an established training year. Staff #1(date of hire: 8/2010) and Staff #2 (date of hire: 4/27/16) did not have the required 24 hours of training. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | All staff training requirements will now follow a calendar year rather than DOH.
((the calendar year is 1/1-12/31 - CH 3/13/18)) |
12/29/2017
| Implemented |
2380.36(e) | There was no record of fire safety training for staff #1. Repeat violation 11/17/2016. | Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff #1 will now be required to sign the fire safety training attendance sheet.
((Fire Safety training was completed on 12/29/17 - CH 3/13/18)) |
12/29/2017
| Implemented |
2380.84 | The annual fire safety inspection was done on 5/12/17. There's no other fire safety inspection on file so it couldn't be determined if it was done annually. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | All previous fire safety inspections will be maintained along side current inspections. |
01/05/2018
| Implemented |
2380.89(c) | The monthly fire drill record did not list which exits are utilized during fire drills. | 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. | A checkbox for rear and front exits have been added to the fire drill form. |
01/05/2018
| Implemented |
2380.89(e) | Due to exits not being documented in the fire drill record, it was unknown if alternate routes were utilized. | Alternate exit routes shall be used during fire drills. | A checkbox for alternated exit routes is now listed on the fire drill form and will be completed going forward. |
01/05/2018
| Implemented |
2380.91(a) | Individual #2 had fire safety training on 3/5/15. She didn't have fire safety training again until 3/6/2017, which exceeds the annual requirement. | 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. | A tickler system has been implemented to ensure all fire safety trainings are completed annually.
((The Team Leader is responsible for ensuring fire safety training is completed annually by monitoring the tickler system - CH 3/13/18)) |
01/05/2018
| Implemented |
2380.111(a) | Individual #1 was admitted on 1/5/2012. There are no physical exams for him in his record. Individual #2 was admitted on 3/7/2011. There is no current physical exam in her record. Individual #3 was admitted on 4/29/2013. There are no physical exams for her in her record. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | All staff are now required to 'sign out an individual's record when reviewing an individual's record for updates and changes to ensure all documents remain secure.
((Brass Castle will maintain an electronic copy as a back-up for hard copies in an individual's file. Physicals will be completed in March/April 2018 - CH 3/13/18)) |
01/05/2018
| Implemented |
2380.113(a) | Staff #1 had a physical exam on 6/6/2016. Her 2014 physical exam was not in her file. Repeat violation 11/17/2016. | 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. | All physical exams documentation will be maintained in each staff person's file onsite.
((The Program Specialist will be responsible for ensuring physical exams are in the staff files. Staff #1's 2014 physical has been returned to the file - CH 3/13/18)) |
01/05/2018
| Implemented |
2380.113(c)(2) | Staff #2 had a TB test on 10/23/2015. As of 12/28/2017, she has not had another TB test, which exceeds the requirement. | 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. | Each staff person will receive a reminder notice for all due dates for physical exams and TB tests.
((Staff #2 has been scheduled for a Mantoux test 3/9/18 - CH 3/13/18)) |
01/05/2018
| Implemented |
2380.171(b)(3) | Name, address and telephone number of the person able to give consent for emergency medical treatment was not in the records for Individual #1, Individual #2, and Individual #3. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Name, address and telephone number of the person able to give consent for emergency medical treatment is now part of the record for Individual #1, Individual #2 and Individual #3. |
01/05/2018
| Implemented |
2380.173(1)(ii) | Weight, height, race, hair color, eye color, and identifying marks weren't listed in the records for Individual #1 and Individual #3. Race, hair color, eye color and identifying marks weren't listed in the record for Individual #2. | 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. | A standard identification form has been created which includes weight, height, race, hair color, eye color and other identifying marks and will now be included in every individual's file. |
01/05/2018
| Implemented |
2380.173(1)(iv) | Religious affiliation was not listed in the records for Individual #1, Individual #2, and Individual #3. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Religious affiliation is now included and part of every individual's record. |
01/05/2018
| Implemented |
2380.173(5(ii) | Invitations for Annual ISP meetings were not in the records for Individual #1, Individual #2 and Individual #3. | Each individual¿s record must include the following information: A copy of the invitation to: The annual update meeting. | Invitations for the annual ISP meetings will be placed in each individual's file upon receipt from the SC/plan lead. |
01/05/2018
| Implemented |
2380.173(6)(ii) | The Annual ISP meeting signature sheet was not in the record for Individual #2. | Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting. | The signature sheet for Individual #2 is now included in the file. |
01/05/2018
| Implemented |
2380.181(e)(13)(ii) | The area of motor skills was not evaluated in Individual #1, Individual #2, and Individual #3's annual assessments. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The area of motor skills has been added to the annual assessment form to be used for all assessments going forward. |
12/29/2017
| Implemented |
2380.181(f) | There is no documentation of assessments being sent to the plan team 30 days prior to the ISP meetings for Individual #1, Individual #2, and Individual #3. | 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 checklist has been created to ensure all assessments are forward to the SC at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under 2380.12, 6500, 6400.182 (relating to development annual update and revision of the ISP). |
12/29/2017
| Implemented |
2380.186(a) | Individual #2 had ISP reviews on 12/9/16, 6/9/17, 9/12/17 and 12/8/17. The timeframe between 12/9/16-6/9/17 exceeds the 3 month requirement. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | A tickler system has been implemented to ensure all ISP reviews of the services and expected outcomes are completed every 3 months.
((Program Specialist is responsible for monitoring the tickler system - CH 3/13/18)) |
01/26/2018
| Implemented |
2380.186(b) | Individual #3 did not sign her ISP review dated 3/28/17. Repeat violation 11/17/2016. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Individual #3 has signed her ISP review dated 3/28/17.
((Program Specialist will be responsible for ensuring individuals sign their ISP Reviews. -CH 3/13/18)) |
12/29/2017
| Implemented |