| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.151(e)(4) | Individual #1's current, 11/6/22 assessment states they can have up to 16 hours of unsupervised time in home and community, can safely ride their bike around the community, and evacuate the home independently in an emergency, and contact 911 in an emergency. However, the individual moved to a new home and new town on January 16, 2023. The assessment was not updated to assess their supervision needs at their new home and new town.
The individuals recently updated (March 2023) individual plan states they would need assistance dialing 911, they wouldn't always leave a building if there was a smoke alarm sounding so supervision is necessary, they can ride their bike around town, but the individual's team feels moderate supervision is necessary when outside their area.
Additionally, the individual's assessment and current individual plan include contradicting information regarding the individual assessed supervision needs in the home and in the community. The individual plan states the team agrees upon up to 8 hours of unsupervised time in the home during the day per day, the team agrees upon up to 8 hours of supervised time in the home per day, and the individual is supervised 8 of the hours in a 24-hour period in the community. | The assessment must include the following information: The individual's need for supervision. | Root Cause Analysis: FLP did work with Individual 1 to learn safe routes to travel in the community, but it was not documented. Individual was reassessed for unsupervised time in their new home/community, ability to evacuate in an emergency, and ability to contact 911 in an emergency. The updated assessment will be provided to the team by 5/1/23 and Individual #1's team will meet to discuss the new assessment and possible necessary changes to the ISP. |
05/01/2023
| Implemented |
| 6500.151(e)(9) | Individual #1's current, 11/6/2022 assessment does not include their current scheduled medications. The assessment states in five different locations that the individual currently takes Concerta and Abilify, both medications once daily. However, the family member responsible for the individual's care reports that on 5/23/22 Individual #1's psychiatrist discontinued Abilify. Per the individual's record, at the time of the 4/3/23 inspection, Individual #1 hasn't re-started taking Ability since 5/23/22. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Root cause analysis: PS did not notice the medication change on the psychiatric medication check form when reviewing documents for the assessment update. Individual #1's assessment will be updated to reflect these changes and provided to the team by 5/1/23. |
05/01/2023
| Implemented |
| 6500.182(b) | Individual #1 saw their psychiatrist on 5/23/22 to review their medication being prescribed for a psychotropic reason. The form was scanned and added to the individual's file. The form listed one medication being reviewed, Concerta. After the form was completed, another medication was written in ink on the form, Abilify, and that the medication was to be stopped. The record of who made the note and when was not documented on the record. | Entries in an individual's record must be legible, dated and signed by the person making the entry. | Root Cause Analysis: After the form was reviewed, at a home visit LSP mentioned the psychiatrist stopped prescribing the Abilify. PS made the change to the form the LSP had completed and scanned but did not initial and date. PS and LSP were trained on this regulation and a training sheet will be available upon request by the department. |
04/17/2023
| Implemented |
| 6500.124 | REPEAT from 4/5/22 annual inspection: Individual #1's record stated on 6/27/22 they were going to start attending therapy in September 2022. A monthly monitoring form from 12/19/22 states the individual started therapy but did not report when or how often. The individual's record does not include any records of the individual attending therapy.
Individual #1 has been refusing routine dental cleanings since 2020. The agency reports the individual does not have dental insurance and does not want to spend money out of pocket for a cleaning. The family reported on 6/27/22 a dentist was found and scheduling appointments at least 6 months out from the date, and on 7/15/22 a dentist was accepting appointments on a first come first serve basis. The agency reported that the family member didn't schedule a dental appointment with either dentist because they assumed the individual would cancel anyway. At the time of the 4/6/2023 inspection, the last time the home documented there was an attempt to find a dentist was on 10/24/22. The agency reported to the Department that the reason why the individual is refusing dental appointments is they don't want to pay for a cleaning out of pocket. The home has not attempted to discuss or show the individual how much a dental cleaning out of pocket costs, attempt to work with the individual to save money, or work on obtaining dental insurance so the cleaning can be covered. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. | Root cause analysis: PS did not realize that therapy was not being documented anywhere.
PS was under the impression that documenting refusals of dental care was sufficient in this case.
A monthly tracking sheet for appointments (Doc 5) has been created to track the dates that therapy and all other appointments occur each month.
A sliding scale dental clinic was presented to Individual 1. Individual 1 did not sign a release of information for PS to call with their information to find out what the cost for them would be. They stated they think it is a waste of time and money as they clean their teeth well at home. |
04/17/2023
| Implemented |
| 6500.43(e)(2) | Staff person #1 reported to the Department they were hired on 11/21/22 as a family living specialist and started performing family living specialist duties 12/27/22. The agency, PA Child Corporation, did not attempt to obtain and review their official transcripts or degree, to determine their qualifications for family living specialist, until 3/14/23. | A life sharing specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with persons with an intellectual disability or autism. | Root cause analysis: PD had documentation of PS degree on the resume and PS was working on getting a copy of transcripts. Based on employment history PD assumed PS did have a degree as stated on resume. A pre-hire checklist (Doc 6) has been developed to be used by Human Resources when hiring for positions within the Life Sharing Program. |
04/20/2023
| Implemented |
| 6500.135(g) | Individual #1's 8/22/22 and 11/21/22 medication reviews do not include the dose of Concerta that is prescribed. The family member completing the medication review documents, recorded "Concerta 36 -- 1 a day."
At the time of the 4/3/2023 inspection, Individual #1 had their psychotropic medications reviewed with a licensed physician on 11/21/22 and not again since then. The agency documented on 3/10/2023 that the individual's primary care physician is currently prescribing and reviewing the individual's psychotropic medications but did not have records of this medication review. The agency reported to the Department during the inspection that the individual's primary care physician is not reviewing the individual's psychotropic medications, the reason for prescribing the medications, the dosages ordered, and the need to continue the medication. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Root Cause Analysis: PS missed this detail when reviewing the form prior to approving it. Review forms/retrain Life Sharing Provider and Program Specialist on making sure forms are filled out accurately and completely. |
04/17/2023
| Implemented |
| 6500.156 | Individual #1's individual plan and behavior support plans include a list of behaviors staff are to document every time they occur. The home did not have records or monitoring of these occurrences throughout the year. The home reported that the behavior support person keeps those records, and they are not available to the agency or the individual and the family. The individual's family member is responsible for documenting behavior support data and reporting the information to the individual's team.
The individual's individual plan also includes a crisis intervention plan that described aggressive and escalating behaviors the individual exhibits and that a team meeting must occur within 5 days of a serious incident. The home and family are not monitoring, documenting, or reporting the aggressive and escalating behaviors if they occur.
The individual's plans and assessment document a certain level of allowable unsupervised time in the home and community per day. The agency reports the family member responsible for monitoring care, is not documented or reporting if Individual #1 uses their unsupervised time, when, or how many hours. | The home and the agency shall implement the individual plan, including revisions. | Root cause analysis: PD believed that the BSS was documenting behaviors and was unaware of a requirement for LSP to also document behaviors for the Life Sharing Program.
PS was unaware that the crisis plan was not updated to reflect Individual 1's current behaviors.
The PD will create a behavior tracking sheet for LSP to use to track the occurrence of the behaviors. Work with the BSS to track behaviors and compile data so the team is all aware of the behaviors. Update daily notes to include a section to document use of unsupervised time each day and any concerns. |
04/17/2023
| Implemented |