| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(b)(1) | No assessments have been completed for individuals in program. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | CEO met with Program Specialist on 4/19/18 to review her job description, including new compliance responsibilities added after the licensing review., evidence is provided in the signed new job description (Attachment #56-#57) . In addition, assessments were completed by 4/25/18 for all individuals in the program and emailed to team members within 24 hours thereafter as referenced in Attachment #58, missing assessments for Individual 1 and Individual 2 are also found in Attachments 28-53. |
04/26/2018
| Implemented |
| 2380.36(a) | Staff # 4's hire date was 06/01/17 upon 2380 opening date. Staff orientation occurred 12/16/17. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | This was an incorrect interpretation of the names of the trainings on the training log provided. Clarification of the names we gave trainings and what the evaluators were referencing is indicated in a memo Attachment #74, A new log was created to clarify and be certain that required trainings are also complete prior to working with individuals. Copies of this log are provided for Staff #4 (Attachment #74 and #75) and the Human Resource Documents policy (Attachment #62-#63 ) clarifies the policy in more detail. Compliance responsibility for this rests on the Director and a sample compliance checklist is provided. in Attachment #79 |
04/19/2018
| Implemented |
| 2380.36(a) | Staff # 2 was hired into 2380 program on 06/01/17. Received orientation training on 12/26/17. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | This was an incorrect interpretation of the names of the trainings on the training log provided to evaluators.. Clarification of the names we gave trainings and what the evaluators were referencing is indicated in a memo, Attachment #74. A new log was created for Staff #2 (77-78) and for future employees to clarify and be certain that required trainings are also complete prior to working with individuals. Copies of this log are provided for Staff #4 and the Human Resource Documents policy (Attachment ) clarifies the policy in more detail. Compliance responsibility for this rests on the Director #79. |
04/19/2018
| Implemented |
| 2380.36(d) | Staff # 2 was hired into 2380 program on 06/01/2017. Trained on program planning and implementation on 07/05/17. | Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | This was an incorrect interpretation of the names of the trainings on the training log provided to evaluators.. Clarification of the names we gave trainings and what the evaluators were referencing is indicated in a memo, Attachment #69. A new log was created for Staff #2 (#77-#78) and for future employees to clarify and be certain that required trainings are also complete prior to working with individuals. Copies of this log are provided for Staff #4 and the Human Resource Documents policy (Attachment #62-63 ) clarifies the policy in more detail. Compliance responsibility for this rests on the Director, Attachment #79. |
04/19/2018
| Implemented |
| 2380.82 | Kitchen egress was obstructed by two kitchen chairs. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | The chairs were removed during the operation of the day program (they belong to the landlord). A picture is provided as evidence in Attachment #73. Landlord was informed of the need for the chairs to not block egress when Day Program is in operation. |
04/25/2018
| Implemented |
| 2380.89(d) | Fire drill held on 08/25/17 took 2:52 to evacuate. No repeat drill was held in 08/17. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | Fire Drill policy was modified (Attachment #69 ) to more clearly state the regulation that fire drills with an evacuation time of less than 2 minutes 30 seconds must be completed within the same month. This also became part of the Director's monthly compliance audit. |
04/18/2018
| Implemented |
| 2380.89(e) | Fire drills conducted on 06/29/17 and 07/26/17 did not indicate which exits were used. | Alternate exit routes shall be used during fire drills. | This violation was an error in copying the original forms into black ink to facilitate better reading/ faxing for the evaluators. Since the originals were available and the exits known, the corrected forms are provided in Attachments #70-#71 .The space for indicating exits was and is utilized on the form. A form for the latest drill is included in Attachment #72 . Reviewing accuracy of Fire Drill reporting is part of the Director's monthly compliance audit Attachment #79. |
04/18/2018
| Implemented |
| 2380.89(g) | Fire drills held from 06/17 until 03/18 did not indicate that individuals evacuated to designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | A space was added to the Fire Drill form (Attachment #72 ) and the Fire Drill procedure (Attachment #69) to assure that this regulation is met. This regulation is also part of the Director's monthly compliance audit Attachment #79. |
04/19/2018
| Implemented |
| 2380.91(a) | Individual # 1 was admitted to program upon program opening date of 06/01/17. Initial fire safety training occurred 04/03/18. Individual # 2 was admitted to the program upon program opening date of 06/01/17. Initial fire safety training for Individual # 2 is not contained in record. | 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. | This was an incorrect reading of the record (Attachment #67) that evidenced that these individuals (both #1 and #2) all received Fire Safety training upon admission in June of 2017. The date of the letter certifying that this occurred was 4/3/18, however the body of letter describes the timing of the actual trainings, as no sign-in sheets had been completed at the time of the training. As the formerly provided record states, the initial training was supplemented by a training video created for that purpose so that the concepts reviewed in June could be reinforced with the individuals, beginning in September. In addition, participants had access to the training by the local Fire Marshall on . The record was rewritten to be more clear and obtain individual signatures verifying it, see Attachment #68. |
04/26/2018
| Implemented |
| 2380.111(c)(1) | No documentation that the medical history was reviewed by physican on Individual # 2's 11/09/17 physical. | The physical examination shall include: A review of previous medical history. | A fax was sent on 4/18/19 to the individual¿s physician and returned on 4/25/2018. in which the physician provided the missing information of review of medical history as evidenced in Attachment #65. All physicals were reviewed for missing information, and none were found to be out of compliance. The Intake procedure was modified to clearly describe portions of the provided physical that needed to be reviewed upon intake, per the Intake Process for HCBS Service Users, Attachment #54-#55. Responsibility for compliance was clarified in the job description of the program¿s Director. |
04/25/2018
| Implemented |
| 2380.111(c)(10) | Individual # 1's physical dated 12/28/17 did not include information pertinent to diagnosis and treatment in case of an emergency. Space left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A fax was sent on 4/18/19 to the individual¿s physician and returned on 4/19/18 in which the physician provided the missing information, including pertinent information to diagnosis and treat in case of emergency as evidence in Attachment #65 . All physicals were reviewed for missing information, and none were found to be out of compliance. The Intake procedure was modified to clearly describe portions of the provided physical that needed to be reviewed upon intake, per the Intake Process for HCBS Service Users, Attachment #. Responsibility for compliance was clarified in the job description of the program¿s Director. |
04/19/2018
| Implemented |
| 2380.111(c)(10) | Individual # 2's 11/09/17 physical does 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. | A fax was sent on 4/18/19 to the individual¿s physician and returned on 4/25/2018. in which the physician provided the missing information of medical information pertinent to diagnosis and treat in case of an emergency, Attachment #66 . All physicals were reviewed for missing information, and none were found to be out of compliance. The Intake procedure was modified to clearly describe portions of the provided physical that needed to be reviewed upon intake, per the Intake Process for HCBS Service Users, Attachment #54-#55. Responsibility for compliance was clarified in the job description of the program¿s Director. |
04/25/2018
| Implemented |
| 2380.111(c)(11) | Individual # 1's physical dated 12/28/17 did not include special diet instructions. Space left blank. | The physical examination shall include: Special instructions for an individual's diet. | A fax was sent on 4/18/19 to the individual¿s physician and returned on 4/19/2018. in which the physician provided the missing information of special diet instructions in Attachment #65. All physicals were reviewed for missing information, and none were found to be out of compliance. The Intake procedure was modified to clearly describe portions of the provided physical that needed to be reviewed upon intake, per the Intake Process for HCBS Service Users, Attachment #54-55. Responsibility for compliance was clarified in the job description of the program¿s Director. |
04/19/2018
| Implemented |
| 2380.113(a) | Staff # 1's record did not contain a physical exam. | 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. | Staff #1 received a TB test on 4/14/18 and was cleared to return to work on 4/16/18 after the test was negative without contact with clients. The remainder of the physical was completed on 4/18/18 and is included in Attachments #59-60. Use of the standardized Spectra form assured that the physical met all regulatory requirements, including indication that employee was free from communicable diseases.
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment #61 . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment #62-#63 . |
04/25/2018
| Implemented |
| 2380.113(b) | Staff # 1's record did not contain a physical exam. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | Staff #1 received a TB test on 4/14/18 and was cleared to return to work on 4/16/18 after the test was negative. The remainder of the physical was completed on 4/18/18 and is included in Attachments # 59-60. Use of the standardized Spectra form assured that the physical met all regulatory requirements, including being signed by a licensed physician.
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment #61 . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment #62 . |
04/25/2018
| Implemented |
| 2380.113(c)(1) | Staff # 1's record did not contain a physical exam. | The physical examination shall include: A general physical examination. | Staff #1 received a TB test on 4/14/18 and was cleared to return to work without client contact on 4/16/18 after the test was negative. The remainder of the physical was completed on 4/18/18 and is included in Attachments #59-60. . Use of the standardized Spectra form assured that the physical met all regulatory requirements, including evidence that a physical exam was conducted.
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment #61 . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment #62 . |
04/25/2018
| Implemented |
| 2380.113(c)(2) | Staff # 1's record did not contain a physical exam nor documentation of TB skin testing | 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. | Staff #1 received a TB test on 4/14/18 and was cleared to return to work on 4/16/18 after the test was negative. The remainder of the physical was completed on 4/18/18 and is included in Attachments #59-#60 - Use of the standardized Spectra form assured that the physical met all regulatory requirements, including documentation of TB skin testing.
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment #61 . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment #62 . |
04/25/2018
| Implemented |
| 2380.113(c)(2) | Staff # 4's physical exam dated 03/15/18 did not contain a TB skin test. | 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. | Staff #4 received a TB test on 4/13/18 and was cleared to return to work on 4/16/18 after the test was negative and is included in Attachment #64 .
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment #61 . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment #62-#63 . |
04/25/2018
| Implemented |
| 2380.113(c)(3) | Staff # 1's record did not contain a physical exam. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | Staff #1 received a TB test on 4/14/18 and was cleared to return to work without client contact on 4/16/18 after the test was negative. The remainder of the physical was completed on 4/18/18 and is included in Attachments #59-60- . Use of the standardized Spectra form assured that the physical met all regulatory requirements, including documentation of a physical exam.
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment #61 . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment #62-#63 . |
04/25/2018
| Implemented |
| 2380.113(c)(4) | Staff # 1's record did not contain a physical exam. | The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals. | The remainder of the physical was completed on 4/18/18 and is included in Attachments #59-60 - . Use of the standardized Spectra form assured that the physical met all regulatory requirements, including documentation that employee had no medical problems which might interfere with the safety or health of the individuals.
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment #61 . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment #62-#63 . |
04/25/2018
| Implemented |
| 2380.114(a) | Staff # 1's record did not contain a physical exam. Unable to ascertain communicable disease status. | If a staff person or volunteer has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or a medical problem which might interfere with the health, safety or well-being of the individuals, written authorization from a licensed physician is required for the person to be present at the facility. | Staff #1 received a TB test on 4/14/18 and was cleared to return to work on 4/16/18 after the test was negative. The remainder of the physical was completed on 4/18/18 and is included in Attachments # - . Use of the standardized Spectra form assured that the physical met all regulatory requirements, including indication that employee was free from communicable diseases.
A review of all staff was held and 3 staff were found to not have up to date TB tests and one staff required the needed physical. As of 4/25/18, all staff with direct contact to individuals in the ATF have been cleared to work, per Attachment . The Required Human Resource Documents policy was updated to clearly state that a completed physical as well as negative TB test were required prior to contact with individuals, per Attachment # . |
04/25/2018
| Implemented |
| 2380.181(a) | Individual # 1's date of admission was upon program opening dated 06/01/17. No assessment is contained in the record. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individual¿s assessment was completed and signed on 4/24/2018 and emailed to team members on the 4/26/17. The Referral and Intake Policy in Attachment # 54 ) now includes a reference to the need for the assessment to be completed within the regulatory time frames of 1 year prior or 60 days after admission to the program and annually thereafter. Compliance responsibilities were also clearly described in the improved Program Specialist job description (Attachment #57-#58 and subsequent review by the Program Specialist and Executive Director on 4/19/18.
Assessments for all currently admitted individuals were completed by 4/25/2018, as evidence in the Review table included in Attachment #59 . They were sent to the respective teams within 24 hours of completion. |
04/26/2018
| Implemented |
| 2380.181(a) | No assessment was contained in Individual # 2's record | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individual¿s assessment was completed and signed on 4/24/2018 and emailed to team members on 4/26/17 and is included in Attachment #41-#52. The Referral and Intake Policy in Attachment # 54 ) now includes a reference to the need for the assessment to be completed within the regulatory time frames of 1 year prior or 60 days after admission to the program and annually thereafter. Compliance responsibilities were also clearly described in the improved Program Specialist job description (Attachment #57-#58 and subsequent review by the Program Specialist and Executive Director on 4/19/18.
Assessments for all currently admitted individuals were completed by 4/25/2018, as evidence in the Review table included in Attachment #59 . They were sent to the respective teams within 24 hours of completion. |
04/26/2018
| Implemented |
| 2380.183(7)(i) | Individual # 1's ISP dated 07/26/17 does not state his/her potential to advance in vocational programming | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | Email was sent to individual¿s Supports Coordinator on April 18, 2018 that included the needed vocational summary, as evidenced in Attachment . On 4/25/18, all supports coordinators were provided with a paragraph on vocational programming, as drawn from the newly created Day Program Assessment. Evidence that this was done is documented in Attachment , and copies of actual emails can for other individuals can be provided upon request. Since the vocational programming is now part of the annual assessment, it should be regularly updated as part of the annual ISP meeting and Review. |
04/25/2018
| Implemented |
| 2380.183(7)(i) | Individual # 2's ISP dated 01/10/18 does not include an assessment of the individuals potential to advance in vocational programming | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | Email was sent to individual¿s Supports Coordinator on April 18, 2018 that included the needed vocational summary, as evidenced in Attachment #25 . On 4/25/18, all supports coordinators were provided with a paragraph on vocational programming, as drawn from the newly created Day Program Assessment. Evidence that this was done is documented in Attachment #26 , and copies of actual emails can for other individuals can be provided upon request. Since the vocational programming is now part of the annual assessment, it should be regularly updated as part of the annual ISP meeting and Review. |
04/25/2018
| Implemented |
| 2380.183(7)(iii) | Individual # 1's ISP dated 07/26/17 does not include an assessment of his/her potential to advance in competitive community employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | Email was sent to individual¿s Supports Coordinator on April 18, 2018 that included the needed vocational summary and reference to potential for competitive community employment, as seen in Attachment #24 . On 4/25/18, all supports coordinators were provided with a paragraph on vocational programming, as drawn from the newly created Day Program Assessment, as evidence by Attachment #27 . Since the vocational programming and competitive employment reference is now part of the annual assessment, it should be regularly updated as part of the annual ISP meeting. |
04/25/2018
| Implemented |
| 2380.186(b) | Individual # 1's ISP reviews dated 01/15/18 and 09/29/17 were not signed by the individual. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | IMMEDIATE: Director Yolanda Cucinotta facilitated the signing of the quarterly ISP reviews by the individual. Copies of the documents in question are included in the supporting documentation, Attachments #1 and #2. A review of all quarterlies for fiscal year 2017-2018 was conducted by the Director. Errors were found and corrected, per attachment #6.
FUTURE: In order to prevent future occurrences, the Service Documentation (Attachments #3-4) policy was updated to include the need for the individuals signature. In addition, the template for ISP Quarterly Reviews was modified by Executive Director Maleita Olson to add signature lines for both the Program Specialist as well as the individual served. It is expected that by 4/30/18, Spectra will have 100% compliance with this regulation for the 3rd Quarter ISP reviews for all individuals served for the time period January-March, 2018. Maleita Olson retrained Program Specialist Alli Domers on 4/19/18 on the need to be sure that all Quarterly ISP reviews are signed both by her and by the individual. In addition, the Director Yoland Cucinotta was assigned a record audit responsibility to her job description (Attachment #5) that will result in all reports being checked for proper information and signatures at least bi-monthly. |
04/19/2018
| Implemented |
| 2380.186(b) | ISP quarterly reviews for individual # 2 were not signed by the individual. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | IMMEDIATE: Director Yolanda Cucinotta facilitated the signing of the quarterly ISP reviews by the individual. Copies of the documents in question are included in the supporting documentation, Attachments #7 and #8. A review of all quarterlies for fiscal year 2017-2018 was conducted by the Director. One additional document was found to be unsigned by the individual and corrected, per attachment #6.
FUTURE: In order to prevent future occurrences, the Service Documentation (Attachments #3-4) policy was updated to include the need for the individual¿s signature. In addition, the template for ISP Quarterly Reviews was modified by Executive Director Maleita Olson to add signature lines for both the Program Specialist as well as the individual served. It is expected that by 4/30/18, Spectra will have 100% compliance with this regulation for the 3rd Quarter ISP reviews for all individuals served for the time period January-March, 2018. Maleita Olson retrained Program Specialist Alli Domers on 4/19/18 on the need to be sure that all Quarterly ISP reviews are signed both by her and by the individual. In addition, the Director Yolanda Cucinotta was assigned a record audit responsibility to her job description (Attachment #5) that will result in all reports being checked for proper information and signatures at least monthly. |
04/19/2018
| Implemented |
| 2380.186(c)(2) | Individual # 1's ISP reviews did not include a review of the Behavior Support Plan. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | IMMEDIATE: Maleita Olson trained all BSC¿s on 4/16/18 in the need to integrate quarterly BSC report into Quarterly ISP review, since in the past BSP goals were not specifically referenced in the old form under New Concerns. Meeting was held on 4/17/18 between CEO Maleita Olson and Director Yolanda Cucinotta to redesign Quarterly Behavior Support plan report to include recommendations made by licensing inspectors. Quarterly Behavior Support Plan reviews were completed for the first two quarters of 2017-2018 by the CEO and Program Specialist for the individuals reviewed at licensing, seen in attachments #9-#12. Yolanda Cucinotta reviewed all remaining Quarterly ISP Reviews and discovered additional Quarterly Reviews did not make specific reference to BSP goals and outcomes. Quarterly Review addenda were completed for the remaining reports as seen on Attachment #13.
FUTURE: In order to prevent future occurrences, the Service Documentation (Attachments #3-4) policy was updated to include the need for the BSP goals and outcomes to be included in Quarterly ISP Reviews for the Day Program. In addition, the template for ISP Quarterly Reviews was modified by Executive Director Maleita Olson to add BSP outcomes. It is expected that by 4/30/18, Spectra will have 100% compliance with this regulation for the 3rd Quarter ISP reviews for all individuals served for the time period January-March, 2018. Maleita Olson retrained Program Specialist Alli Domers on 4/19/18 on the need to be sure that all Quarterly ISP reviews include BSP goals and outcomes. In addition, the Director Yolanda Cucinotta was assigned a record audit responsibility to her job description (Attachment #5) that will result in all reports being checked for proper information and outcomes at least monthly. |
04/30/2018
| Implemented |
| 2380.186(c)(2) | Individual # 2's ISP reviews do not include a review of SEEN plan utilization. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | IMMEDIATE: Maleita Olson trained all BSC¿s on 4/16/18 in the need to integrate quarterly BSC report into Quarterly ISP review, since in the past BSP goals were not specifically referenced in the old form under New Concerns. Meeting was held on 4/17/18 between CEO Maleita Olson and Director Yolanda Cucinotta to redesign Quarterly Behavior Support plan report to include recommendations made by licensing inspectors. Quarterly Behavior Support Plan reviews were completed for the first two quarters of 2017-2018 by the CEO and Program Specialist for the individuals reviewed at licensing, see attachments #56-#57. Yolanda Cucinotta reviewed all remaining Quarterly ISP Reviews and discovered additional Quarterly Reviews did not make specific reference to BSP goals and outcomes, per attachment #13. Quarterly Review addenda were completed for the remaining reports.
FUTURE: In order to prevent future occurrences, the Service Documentation (Attachments #3-4) policy was updated to include the need for the BSP goals and outcomes to be included in Quarterly ISP Reviews for the Day Program. In addition, the template for ISP Quarterly Reviews was modified by Executive Director Maleita Olson to add BSP outcomes. It is expected that by 4/30/18, Spectra will have 100% compliance with this regulation for the 3rd Quarter ISP reviews for all individuals served for the time period January-March, 2018. Maleita Olson retrained Program Specialist Alli Domers on 4/19/18 on the need to be sure that all Quarterly ISP reviews include BSP goals and outcomes. In addition, the Director Yolanda Cucinotta was assigned a record audit responsibility to her job description (Attachment #5) that will result in all reports being checked for proper information and outcomes at least monthly. |
04/30/2018
| Implemented |
| 2380.186(d) | There is no documentation that Individual # 2's ISP reviews were sent to all team members within 30 days of ISP review meetings. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | IMMEDIATE: All Quarterly Reviews for 2017-2018 for all participants were emailed on 4/26/18 to any team members who did not receive them previously. A tracking sheet was created that includes the ISP anniversary date, a column for the meeting date, a target date for sending to the team members, and a compliance column. Responsibility for monitoring compliance is part of Director-Day Services' responsibilities to avoid future lapses. |
04/26/2018
| Implemented |
| 2380.186(e) | There is no documentation that team members were given an option to decline ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | IMMEDIATE: Emails (and in one case a paper letter) were sent on 4/18/18 by Alli Domers inviting team members to respond or decline their opportunity to receive copies of the ISP Review. Team responses are documented in Attachments #8 and #9 for the two individuals reviewed. In addition, emails were sent to team members for each program participant with responses received regarding team member¿s desire for copies of the ISP Quarterly Review, as documented in Attachment #10.
FUTURE: New Quarterly Review forms were created for each individual and a completed copy is provided for two individuals reviewed with demonstration of checkboxes, as evidenced in Attachments #11 and #12, These checkboxes offer the Director-Day Services a clear record to confirm compliance with sending the reviews to team members in her monthly compliance audit. |
04/25/2018
| Implemented |