| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete self assessments of either of their two homes. The location of the home and the date completed was missing from the forms. The forms were not completed in it's entirety. | 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.
| Sunset Support Services has adapted a new Licensing Inspection Instrument Score Sheet in compliance with 6400 regulations. The Program Coordinator will assure nthat a self inspection of all houses will be done 3 to 6 months prior to the agencies certificate of compliance expiration date. The Program Coordinator will be responsible to make any corrective actions in any areas of concern before the official inspection occurs. |
09/29/2015
| Implemented |
| 6400.22(e)(1) | The agency assumed the responsibility of maintaining Individual #1's financial resources and they did not keep a complete and up to date financial record of dates and amounts of deposits and withdrawals for Individual #1 from July 2014 until July 2015. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Individual #1 is currently working for Cambria County Association for the Blind located at 175 Industrial Park Road, Ebensburg, PA., 1593. Individual #1 is paid on a bi-weekly basis. Work checks are made out to him, he signs them. According to Support Coordinator, Don Knopsnyder, the individual is to receive his full amount of pay for the pay period which will be reflected by his signature on his cashed check. Copies of cashed checks will be kept with his financial records as proof that individual received his money. The Support Coordinator will update individual#1's ISP to reflect this. |
09/29/2015
| Implemented |
| 6400.22(e)(2) | The agency assumed the responsibility of maintaining Individual #1's financial resources. Individual #1 was given $70 per week directly for spending money, per agency report at time of licensing. It was not documented from July 2014 to July 2015 that Individual #1 received $70 per week | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | Individual #1 will sign and cash his checks with assistance from staff if needed. Copies of the signed cashed checks will be proof that the individuals funds were given directly to him and will be kept in his financial records. Copies of recent cashed checks are attached. |
09/29/2015
| Implemented |
| 6400.46(i) | Staff #2 had training in first aid and cardio-pulmonary on 11/19/13 and not again since. She was due on 11/19/14. Staff #2's certificate did not specify that the training was good for two years. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Sunset Support Services are in the process of training their staff as trainers in CPR/and First Aid as opposed to using an outside source to assure all staff have valid certifications before being scheduled to work with the individuals. Training for said staff will be complete as of October 2015. The agency's CPR/First Aid Trainer will keep a calendar record for all staff to assure CPR and First Aid is completed in a timely manner and in compliance. All staff will have their CPR/First Aid cards attached to their files as proof of certification for 2 years as stated on the certification cards. A copy of Staff #2's certification card has been updated and is attached. |
09/29/2015
| Implemented |
| 6400.141(c)(6) | Individual #1's date of entry was 4/14/14 and a tuberculin skin test was not completed until 3/23/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Medication Administration Trainer will attend all initial and annual individual's physical assessment appointments to assure Mantoux testing is done and recorded properly. A new physical form for individuals has been implemented with all fields required per 6400 regulations. A copy of the new physical form is attached. |
09/29/2015
| Implemented |
| 6400.141(c)(15) | The physical exam for Individual #1 did not include special instruction for the Individual's diet. There was not a spot on the physical form for diet information to be recorded. | The physical examination shall include:Special instructions for the individual's diet. | A new physical for individuals residing at Sunset Support Services has been adapted with all the required fields including special diet. The Medication Administration Trainer will attend all physicals to assure all fields are filled in correctly according to 6400 regulations. New physical form attached. |
09/29/2015
| Implemented |
| 6400.144 | On 12/23/14 Individual #1's primary care physician Dr. Raymond, wrote a script that Individual #1's blood pressure and weight were to be recorded 2 to 3 times per week. The agency was not checking or recording either. | 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.
| The recommendation for individual #1's blood pressure and weight has been added to his Medication Administration Record to be done 3 times weekly. The Medication Administration Trainer as well as the Team Leader will review this on a weekly basis to assure the treatment is being administered and documented per Dr. Raymond's order. Copy of MAR attached. |
09/29/2015
| Implemented |
| 6400.151(c)(3) | REPEAT: Staff #2 and #3 had their physicals completed in 2013 but it did not note whether they were free from communicable diseases or not. Since being cited in 2014, Staff #2 and #3 still have not received clarification from a physician that states whether they are free from communicable diseases or not. | 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. | Staff #2 and #3 have taken their physicals back to the physician who examined them at that time. The physician has filled out the communicable disease field, signed and dated for both staff. Copies of the physicals are attached. |
09/29/2015
| Implemented |
| 6400.163(c) | Individual #1 was prescribed prozac for a diagnosis of depression. Individual #1 did not have a medication review completed with a primary care physician or certified nurse practitioner until 12/17/14. Individual #1's date of entry was 4/14/14. The medication reviews that were completed, did not list the medication(s), dosage(s), the need to continue the medication(s), and the reason for prescribing the medication(s). | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Support Coordinator and Program Specialist will develop a protocol to assure social, emotional and environmental needs of the individual are being met if prescribed medication for a diagnosed psychiatric illness. This will be done through a SEEN Plan. Attached. |
09/29/2015
| Implemented |
| 6400.167(b) | On 5/8/15, Individual #1's Neurontin was prescribed to be administered as 200mg in the morning and 400mg at night. It was being administered the opposite as it was prescribed. Also on 5/8/15, Individual #1's Prozac was prescribed to be administered as 30mg at night. At the time of licensing on 6/30/15, Prozac was being administered 20mg at night. On 5/29/15, Individual #1's physician increased his Neurontin to 300mg in the morning and 600mg at night. This was not administered as prescribed until 6/2/15. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The Medication Administration Trainer will review all medical consults including new, changed or discontinued prescriptions within 24 hours after the appointment to assure all medications are given in the proper time frame as stated in the 6400 regulations. |
09/29/2015
| Implemented |
| 6400.181(a) | Individual #1's assessments completed on 5/7/14 and 5/18/15 were not completed by a program specialist or someone with program specialist qualifications. They were completed by a residential service worker. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Director of Sunset Support Service will ensure the Program Specialist will complete, sign and date all individual assessments within 60 days of admittance. The Program Specialist will complete a new assessment there after annually. |
09/28/2015
| Implemented |
| 6400.181(c) | The assessment for Individual #1 did not reference where or how the information was obtained. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | A new assessment in compliance with the 6400 regulations has been implemented which contains this field. The Program Specialist will assure that the reference as to how the information on the assessment was obtained will be in contained the assessment. |
09/28/2015
| Implemented |
| 6400.181(d) | A program specialist did not complete the assessment for Individual #1, nor sign and date the assessment. | The program specialist shall sign and date the assessment. | The Director of Sunset Support Services will assure the Program Specialist completes, signs and dates the assessments initially and annually. The Director will review the assessments when completed to assure they are signed and dated by the Program Specialist. |
09/28/2015
| Implemented |
| 6400.181(e)(1) | The assessment for Individual #1 did not include functional strengths, needs, and preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | A new assessment in compliance with 6400 regulations has been implemented. The Program Specialist will assure the functional strengths, needs and preferences of the individual are contained and documented in the assessment. |
09/28/2015
| Implemented |
| 6400.181(e)(2) | The assessment for Individual #1 did not include likes, dislikes, and interests of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | A new assessment in compliance with 6400 regulations has been implemented. The Program Specialist will assure the likes, dislikes and the interests of the individual are contained and documented in the assessment. |
09/28/2015
| Implemented |
| 6400.181(e)(3)(i) | The assessment for Individual #1 did not include the Individual's current level of performance in acquisition of functional skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | A new assessment in compliance with 6400 regulations has been implemented. The Program Specialist will assure the individuals level of performance and progress in the area of acquisition of functional skills is contained and documented in the assessment. |
09/28/2015
| Implemented |
| 6400.181(e)(3)(ii) | The assessment for Individual #1 did not include the Individual's current level of performance in communication. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | A new assessment in compliance with 6400 regulations has been implemented. The Program Specialist will assure the field of performance and progress in the area of communication is present on the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(6) | The assessment for Individual #1 did not include the Individual's ability to safely use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | A new assessment in compliance with 6400 regulations has been implemented. The Program Specialist will assure the individual's ability to safely use or avoid poisonous materials are contained and documented in the assessment. |
09/28/2015
| Implemented |
| 6400.181(e)(7) | The assessment for Individual #1 did not include their knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | A new assessment in compliance with 6400 regulation has been implemented. The Program Specialist will assure the danger of heat sources and the ability to quickly move away from heat sources exceeding 120 degrees are contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(8) | The assessment for Individual #1 did not include their ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | A new assessment in compliance with 6400 regulations has been implemented. The Program Specialist will assure the field of the ability to evacuate in the event of a fire are contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(12) | The assessment for Individual #1 did not include recommendations for specific areas of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | A new assessment in compliance with 6400 regulations has been implemented in this field. The Program Specialist will assure the field of recommendations for specific areas of training, programming and services are contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(i) | The assessment for Individual #1 did not include their progress and current level in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| A new assessment in compliance with 6400 regulations has been implemented in this field. The Program Specialist will assure progress over the last 365 calendar days in the current level of health are contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(ii) | The assessment for Individual #1 did not include their progress and current level in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | A new assessment in compliance with 6400 regulations has been implemented. The Program Specialist will assure the field of progress over the last 365 calendar days on the current level of motor and communication skills is contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(iii) | The assessment for Individual #1 did not include their progress and current level in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | A new assessment in compliance with 6400 regulations has been implemented with this field. The Program Specialist will assure the field of activities of residential living is contained in the assessment and documented over the last 365 calendar days. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(iv) | The assessment for Individual #1 did not include their progress and current level in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | A new assessment in compliance with 6400 regulations has been implemented with this field. The Program Specialist will assure the field of personal adjustment in the last 365 calendar days is contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(v) | The assessment for Individual #1 did not include their progress and current level in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | A new assessment in compliance with 6400 regulations has been implemented with this field. The Program Specialist will assure the field of socialization over the last 365 calendar days is contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(vi) | The assessment for Individual #1 did not include their progress and current level in recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | A new assessment in compliance with 6400 regulations has been implemented with this field. The Program Specialist will assure the field of recreation in the last 365 calendar days are contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(vii) | The assessment for Individual #1 did not include their progress and current level in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| A new assessment in compliance with 6400 regulations has been implemented with this field. The Program Specialist will assure the field of financial independence over the last 365 calendar days are contained in the assessment and documented. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(viii) | The assessment for Individual #1 did not include their progress and current level in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | A new assessment in compliance with 6400 regulations containing this field has been implemented. The Program Specialist will assure the field of managing personal property is contained in the assessment and documented. |
09/29/2015
| Implemented |
| 6400.181(e)(13)(ix) | The assessment for Individual #1 did not include their progress and current level in community-integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | A new assessment in compliance with6400 regulations with this field has been implemented. The Program Specialist will assure the field of community integration is contained in the assessment and documented. |
09/29/2015
| Implemented |
| 6400.181(e)(14) | The assessment for Individual #1 did not include their progress and current level in their knowledge of water safety and ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | A new assessment with this field has been implemented. The Program Specialist will assure this field is contained in the assessment and documented. |
09/29/2015
| Implemented |
| 6400.181(f) | The assessment for Individual #1 was not sent to the individual or any team members. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Sunset Support Services Program Case Coordinators are responsible to ensure all plan team members receive copies of the individual's ISP meeting. Sunset Support Services Program Case Coordinators will create a 30 day calendar alert as to when the new ISP should be available, email reminders will be sent to the Support Coordinator and copies of the emails will be filed in the individual's Program Books as proof that the ISP has been made available. |
09/29/2015
| Implemented |
| 6400.183(5) | Individual #1 was prescribed Prozac for depression and did not have a protocol to address the social, emotional, and environmental needs of the individual. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | The Support Coordinator and the Program Specialist will develop a protocol to assure social, emotional and environmental needs of all individuals who are being prescribed medication for diagnosed psychiatric illnesses. This plan will be conducted and modified as needed and documented in the ISP. |
09/28/2015
| Implemented |
| 6400.183(7)(iv) | The Individual Support Plan (ISP) for Individual #1 did not contain their potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (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.
| The Support Coordinator and Program Specialist will monitor and record Individual #1"s work production as documented by his supervisor at CCABH and offer suggestions on ways to improve work efficiency and productivity which can lead to possible advancement in the work force. This will also depend on individual #1's satisfaction with his job and productivity. The Support Coordinator will record this in the individual's ISP. |
09/28/2015
| Implemented |
| 6400.184(a)(1)(ii) | The program specialist from Sunset Support Services was not in attendance for Individual #1's Individual Support Plan (ISP) meeting. | A plan team must include as its members the following: A program specialist or family living specialist, as applicable, from each provider delivering a service to the individual. | The Director of Sunset Support Services, Carla Smay, will keep the Program Specialist updated as to when all ISP meetings are scheduled and will assure the Program Specialist is in attendance. This will be communicated by email which will be placed in the individuals Program Books as proof of when there are scheduled meeting. |
09/28/2015
| Implemented |
| 6400.184(a)(1)(iii) | A direct service worker from Sunset Support Services was not in attendance for Individual #1's Individual Support Plan (ISP) meeting. | A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering services to the individual. | The Program Specialist will alert the Team Leaders of ISP review dates and meetings to allow him/ her time to schedule their self and at least one other staff to attend the meeting. The Team Leader will be responsible to schedule staff to attend the ISP meetings. |
09/28/2015
| Implemented |
| 6400.186(b) | Individual #1 and the program specialist did not date any Individual Support Plan (ISP) reviews upon review of the ISP. The date was pre-populated and it only included a month and a year. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The Director of Sunset Support Services will assure the Program Specialist and the individual review and sign the signature sheet of the ISP. The correct date including the month, day and year will be on the signature. The Director will review all ISPs to assure the correct dates and signatures are present. |
09/28/2015
| Implemented |
| 6400.186(d) | The Individual Support Plan (ISP) reviews for Individual #1 were not sent to the individual or any plan team member. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Sunset Support Services Program Case Coordinators are responsible to ensure all plan team members receive copies of the individual's ISP within 30 days after the ISP meeting. Sunset Support Services Program Case Coordinators will create a 30 day calendar alert as to when the new ISP should be available from the Support Coordinator. If the ISP is not available, email reminders will be sent to the Support Coordinator and copies of the emails will be filed in the individual's Program Books as proof that the ISP have not been mailed out. |
09/28/2015
| Implemented |
| 6400.186(e) | The option to decline the Individual Support Plan (ISP) review documentation was not given to any plan team member of Individual #1. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Manager, will ensure there is a declination Sign Off sheet for all individuals. Team Leaders and Orientation Trainer will assure all staff read the ISP/BSP's and sign off accordingly including the month, day and year.
|
09/28/2015
| Implemented |
| 6400.213(11) | The identification sheet for Individual #1 stated that their religion was unknown. However the assessment for Individual #1 listed their religion as Christian. The Individual Support Plan (ISP) for Individual #1 stated that they do not take any medications however they were taking Prozac which was listed in the ISP. Individual #1 had a script from his doctor on 13/23/14 that he was to follow a 1800 calorie diet, decrease his soda intake to 3 sodas per day and increase his water intake. Individual #1's physical did not list a diet and his assessment only stated he was on an 1800 calorie diet. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Individual #1's identification sheets were reviewed and updated to match his assessment. Identification sheets will be reviewed by Angel Watt, human resources, on a weekly basis to assure all information is accurate, matches assessments and ISP's, and kept up to date. All updates will be sent to the Support Coordinators to update ISP's. Revised Identification Sheet for individual #1 attached. |
09/28/2015
| Implemented |