| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment completed by the agency between 2/24/16 and 2/26/16 was not fully completed. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The licensing instrument was completed for the idenitified site. The compliance officer, is aware of the necessity of completing the licensing inspection instrument in full. The completion of the the form was discussed, and staff member was retrained on 6/14/2016. A face to face training was conducted on the appropriate way to utilize the form. In addition a review of the previous completed Inspection Instruments were reviewed to increase the level of understanding. As of 7/21/2016 an additional copy of the licensing instrument was provided for completion. During the week of July 25, 2016 a new instrument was completed for each residential site. The completed tools were then reviewed the immediate supervisor. Ongoing weekly site checks for compliance have been continuous, and will continue throughout the fiscal year. Jason Garland Jr. was retrained on this area and educated on the importance of the documents. There were no further issues regarding the document or the steps for completion. It was determined that the Compliance Officer will complete the document monthly. CEO will review the documents to for accurate completion. |
08/06/2016
| Implemented |
| 6400.71 | The telephone number of the nearest ambulance was not on or by the telephone in the living room area of the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The telephone numbers relevant to this regulation were posted and made visible to staff members at the identified site. Compliance Officer was retrained on the items that must be reviewed on the licensing inspection tool to remain in compliance. Compliance Officer was retrained by CEO during June 2016. Compliance Officer has made these changes and has ensured they were present at the residential site.[Immediately and at least quarterly, the CEO and/or compliance officers shall complete an onsite check of the all telephones in the community homes to ensure all required telephone numbers are on or by all telephone with an outside line. Documentation of all on site checks shall be kept. (AS 8/22/15)] |
08/06/2016
| Implemented |
| 6400.110(b) | The smoke detector located in the common hallway is 23 feet from Bedroom #3. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | A new smoke detector was purchased and installed at the site in the hallway outside of the participants door. The smoke detector is operable, and within compliance regarding distance and hearing for the participant. The smoke detector is now located in a safe distance to enable compliance with state regulations. Compliace Officer installed the smoke detector at the residential site. Compliace Officer will continue to check the battery and operation of the smoke detectors at each residential site. Compliance Officer was made aware of the violation after the state inspection. Compliance Officer received retraining regrading the Chapter 6400 regulations from CEO.[The compliance officer or designated staff person shall completed at least monthly checks of all smoke detectors in all community homes to ensure they are in working order and have located in each home as required. Documentation of monthly checks shall be kept. (AS 8/22/16)] |
08/06/2016
| Implemented |
| 6400.141(c)(14) | The physical examination, dated 4/4/16 for Individual #1, 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. | The necessity of form completion has been at the forefront of training. Those individuals taking participants to medical appointments have been made aware of the neceesity of accurate completion of forms. This information was disseminated via the Program Specialist to the House Supervisors. There were no further concerns about document completion. Program Specialist gathered information from the family indicating the preferred hospital in case of an emergency was UPMC Passavant, and contact with either parents as they have guardianship. A quarterly review of these records will occur with the House Supervisors. Dates of the review are scheduled for October, January, April, and July.[Individual #1 physical examination dated 4/4/16 was updated on 8/23/16 to include medical information pertinent to diagnosis and treatment in case of an emergency. Within 1 month of receipt of the plan of correction, CEO shall train staff persons responsible for ensuring individual have initial and annual physical examination of required information as per 6400.141(c)(1)-(15). Within one month of receipt of the plan of correction, annually and prior to entering into the individuals' records, the CEO or designated management staff person shall review all individual residing in community homes current physical examination to ensure all documentation is completed with the required information and there are not any required areas left blank. Documentation of reviews shall be kept. (AS 9/1/16)] |
08/06/2016
| Implemented |
| 6400.151(c)(3) | The physical examination dated 9/25/15 for Direct Service Worker #1 did not include a signed statement that the staff person is free of communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Program Specialist gathered documentation for the creation of a new form to include new hires to address if they are free on contagious disease. After the violation was determined a new form was created to address the area of concern. The identified employees were instructed to get a new physical to determine that they do not currently have a contagious disease. The administrative assistant has reviewed current employee files to remedy the issue. A review of records determined employees requiring this update to their file. The identified employees completed the given physicals to rectify the situation. A monthly review of employee files will occur going forward to identify documentation errors. The adminstrative assistant has been retrained by Program Specialist on this information as of June 2016. CEO provided education to Administrative Assistant as of August 2016. Please see the attachments, as the identified employee completed the physical. New Hires will be provided this form prior to the start of new employee orientation.[Prior to entering into staff record, designated management staff person will review staff physical examinations to ensure all required information is present. Documentation of reviews shall be kept. (AS 8/22/16)] |
08/06/2016
| Implemented |
| 6400.186(e) | The program specialist did not notify the plan team members including the day program provider of the option to decline the ISP review documentation for Individual #1. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Paperwork has been mailed by the adminstrative assistant to each participant family and treatment team providing the opportunity to decline the reciept of the ISP Quarterly Review, as of June 2016. At the time of August 2016, there have not been any declinations of the quarterly review. The letter to decline the Quarterly Review was drafted and completed by the Program Specialist, following retraining from the CEO post inspection.[The program specialist shall review all individuals' ISPs, invitation letters and other documentation to ensure the entire team is included in being notified of the option to decline. Documentation of correspondence of notifications shall be kept. (AS 8/22/16)] |
08/06/2016
| Implemented |