| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(b) | The agency shall use the Department's licensing inspection instrument for this chapter to measure and record compliance. The licensing inspection document completed on 1/12/2023 was not the correct form submitted. | The agency shall use the Department's licensing inspection instrument for this chapter to measure and record compliance. | Fixing the Immediate Problem:
WHO: CEO will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will complete the Self-Assessment Tool on the proper form.
WHEN and HOW: The Family Living Specialist will complete the Self-Assessment Tool on the proper form by March 17, 2023, which will allow Focus Behavioral Health to implement other plans of corrections prior to the completion. Kayla Faloon will complete this plan of correction by re-reviewing and re-inspection individual files and site locations. The proper form will be obtained from ODP's direct website. |
03/17/2023
| Implemented |
| 6500.23(d) | Staff #1's criminal history check was completed on 6/28/21, this is outside the no more than a year prior. Individual #1's date of admission to the Focus Behavioral Health 6500 program is 7/1/22. There were no other criminal history checks completed. | Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to an individual living or receiving respite care in the home. | Fixing the Immediate Problem:
WHO: CEO will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require background checks of all family members residing in the home over the age of 18. Background checks are not to be older than 1 year.
WHEN and HOW: The CEO will run a PA State Background Clearance for Staff #1 on 2/8/23. |
03/17/2023
| Implemented |
| 6500.110(c) | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually -- Individual #1's date of admission 7/1/22 with new provider Focus Behavioral Health. The fire safety training was held 5/1/22. The training was held before the new admission date. | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require Fire Safety Trainings to be completed no sooner than 31 days prior to an individual moving into a home.
WHEN and HOW: The CEO will train Family, Individuals, and Children on the Fire Safety Training by 2/10/23. |
03/17/2023
| Implemented |
| 6500.121(a) | - An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
The physical exam for Individual #1 was completed late- 10/4/22, the previous exam was completed 8/4/21. Individual #1's date of admission is 7/1/22. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require Individual Physicals to be completed no later than 1 year apart. When scheduling issues occur, Focus must document such issues.
WHEN and HOW: Individual #1's physical was obtained on 10/4/22; late due to scheduling issues with the doctor. |
03/17/2023
| Implemented |
| 6500.121(c)(12) | Physical limitations of the individual- was left blank on the annual physical exam 10/4/22 for Individual #1. | The physical examination shall include: Physical limitations of the individual. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require Individual Physicals to be completed in its entirety by a physician.
WHEN and HOW: The Family Living Specialist is to assist Individual #1 in obtaining an updated physical form which includes physical limitations clarification. Updated physical will be obtained by 3/17/23. The FLS will re-review all physicals for all individuals and request further information if needed by 3/17/23. |
03/17/2023
| Implemented |
| 6500.121(c)(14) | Medical information pertinent to diagnosis and treatment in case of an emergency was left blank on the annual physical exam 10/4/22 for Individual #1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require Individual Physicals to be completed in its entirety by a physician.
WHEN and HOW: The FLS is to assist Individual #1 in obtaining an updated physical form which includes medical information pertinent to the diagnosis. Updated physical form is to be obtained by 3/17/23. The FLS will re-review all physicals for all individuals and request further information if needed by 3/17/23. |
03/14/2023
| Implemented |
| 6500.181(b)(1) | This information is missing on the Individual Record template for Individual #1. | Emergency information for an individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of emergency. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require an Individual Record Template to be completed in its entirety. The Individual Record Template must include the relationship of Emergency Contact.
WHEN and HOW: The FLS will complete new Individual Record Templates for all individuals by 3/17/23. The FLS will re-review all Individual Record Templates for completion for all individuals by 3/17/23. |
03/17/2023
| Implemented |
| 6500.181(b)(2) | The name, address and telephone number of the individual's physician or source of health care.
This information is missing from the Individual Record Template for Individual #1. | Emergency information for an individual shall include the following: The name, address and telephone number of the individual's physician or source of health care. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require an Individual Record Template to be completed in its entirety. The Individual Record Template must include Name, Address, and Phone Number of Individual's Physician.
WHEN and HOW: The FLS will complete new Individual Record Templates for all individuals by 3/17/23. The FLS will re-review all Individual Record Templates for completion for all individuals by 3/17/23. |
03/17/2023
| Implemented |
| 6500.181(b)(3) | The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. This information is missing from the Individual Record Template for Individual #1. | Emergency information for an individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require an Individual Record Template to be completed in its entirety. The individual record template must include the Name, Address, and Phone Number of the person who is authorized to give consent for emergency medical treatment.
WHEN and HOW: The FLS will complete new Individual Record Templates for all individuals by 3/17/23. The FSL will re-review all Individual Record Templates for completion for all individuals by 3/17/23. |
03/17/2023
| Implemented |
| 6500.125(c)(3) | The physical examination shall include: A signed statement that the staff person is free of communicable diseases. The physical exam 4/25/22 for Staff #1 did not contain a statement free from communicable diseases.
The physical exam 11/28/21 for Staff #2 did not contain a statement free from communicable diseases.
The physical exam 12/14/21 for Staff #4 did not contain a statement free from communicable diseases. | The physical examination shall include: (3) A signed statement that the person is free of communicable diseases or specific precautions to be taken if the person has a communicable disease. | 6500.125(c)(3) - Missing communicable disease statement
Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: Staff members in all homes that do not have a signed statement showing they are free from communicable diseases must obtain one.
WHEN and HOW: The CEO will assist staff in obtaining the correct form and require the form to be completed and signed by 3/17/23. |
03/17/2023
| Implemented |
| 6500.32(l) | The following rights were not reviewed with Individual #1 on 6/30/22- 32(l), 32(m), 32(n), 32(o), 32r(1), 32r(2), 32r(3), 32r(4), 32r(5), 32s(1), 32t, 32u, 32v, 33a, 33b. These rights were not on the signed rights documentation that Individual #1 signed. | An individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time. | WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: The following rights were not reviewed with Individual #1 on 6/30/22- 32(l), 32(m), 32(n), 32(o), 32r(1), 32r(2), 32r(3), 32r(4), 32r(5), 32s(1), 32t, 32u, 32v, 33a, 33b.
WHEN and HOW: The Family Living Specialist will review the above individual rights with all individuals by 2/27/23.
Plan to Prevent Future Occurrences:
The CEO will update Focus Behavioral Health's individual rights template to include all rights. This is to be completed by 2/27/23. |
02/27/2023
| Implemented |