| 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 |
| 6400.21(c) | Direct Service Worker #1, date of hire 7/14/15, did not have a completed Pennsylvania criminal record check; the request was made prior to employment although not completed. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| A thourough review of the violation and the subsequent paremeters to reduce the risk of further occurrence have been addressed. Each employee with a role in executing the corrective action plan has been retrained and educated by the appropriate superior. Efforts to eliminate reocurrence are ongoing, and are reflected in current agecy records. All identified employees, including CEO, Program Specialist, Administrative Assistant, House Supervsiors, and Residential Staff are aware of these issues of non-compliance. All identified team members are working to reduce the risk of reoccurence as identified above. A copy of the certificates are on file. [Immediately and prior to hire for all new employees, CEO or designated management staff person shall review all current employees' criminal record checks to ensure all are completed as required. Documentation of reviews shall be kept. (AS 8/22/16)] |
08/06/2016
| Implemented |
| 6400.141(c)(14) | The physical examination, dated 10/15/15 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 any Allegheny Valley Health Network facility, 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's annual physical examination due 10/15/16 shall be updated 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 |
| 6400.162(a) | Individual #1 is prescribed Clobetasol Cream, .05%, apply topically to affected areas on body twice a day for psoriasis. The pharmaceutical label on the Clobetasol cream had hand written "PRN for boil." | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | Medication administration practices were reviewed as a follow up to medication having a label and handwriting on the bottle, with the staff administering medication at the site. Designated Agency Personel, with current Practicum Observer Certificate reviewed this information with all medication trained staff at the site to ensure compliance. PDC Pharmacy was contacted to ensure proper labeling was done for each prescribed medication. There are no longer medications at the site with this violation. [Within 30 days of receipt of the plan of correction and at least monthly, the CEO or designated management staff shall review all individuals' doctors' orders, medications and prescription labels and Medication logs to ensure all individuals are being administered medications as prescribed and accurately documented. (AS 8/22/16)] |
08/06/2016
| Implemented |