| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The following staff had criminal history record checks requested beyond 5 days after date of hire: Staff #3 DOH 05/05/16-Request 05/18/16, Staff #4 DOH 07/28/16-Request 08/02/16, Staff #5 DOH 07/26/16-Request 08/02/16, Staff #6 DOH 09/10/16-Request 09/19/16, Staff #7 DOH 10/21/16-Request 10/27/16, Staff#8 DOH 09/27/16-Request 10/27/16, Staff#9 DOH-05/03/15-Request-05/13/16. Staff #9 left agency and returned, however criminal check was beyond 12 months and a new one was not requested. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Sunset Support Services will ensure that no one is hired before his/her clearances has been run. |
02/15/2017
| Implemented |
| 6400.22(d)(2) | Individual #1's financial disbursements made to or for him/her were not all included with documentation. No bank statements provided. Unclear what month end balances were. Beginning balance did not match with end balance of previous month. End balance of Oct 2016 was $0. Beginning balance of November 2016 was $50. | (2) Disbursements made to or for the individual.
| Sunset Support Services opened a checking account to ensure all documentation is kept complete and accurate, as well as all documentation is available. |
02/15/2017
| Implemented |
| 6400.46(f) | Fires safety training for Staff # 2 was conducted on 07/01/15 and not again until 07/03/16. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Sunset Support Services will implement a computer print out of all current trainings and up coming annual training due dates to ensure all staff remain in compliance. |
02/15/2017
| Implemented |
| 6400.141(c)(3) | Individual # 1's physical exam dated 03/24/16 does not include immunization information. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Sunset Support Services has implemented a new physical form that includes immunizations. |
02/15/2017
| Implemented |
| 6400.151(c)(2) | Individual # 2's 05/04/16 physical stated a TB test was administered on 05/04/16, however it did not indicate the date that the results were read. There is a signature of who read the test results and results indicated negative but no date. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if 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, licensed physician's assistant or certified nurse practitioner. | Sunset Support Services LPN will review all medical forms to ensure everything is properly documented to remain in compliance. |
02/15/2017
| Implemented |
| 6400.181(e)(10) | Individual # 1's lifetime medical history was not included in his/her 2/20/16 assessment. | The assessment must include the following information: A lifetime medical history. | Sunset Support Services LPN will complete and update lifetime medical history. |
02/15/2017
| Implemented |
| 6400.181(e)(13)(i) | Repeat 06/30/15- Individual # 1's 02/20/16 assessment did not include progress and growth in the area of 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.
| Sunset Support Services will complete monthly reports to ensure that the progress and growth in the area of health will be complete and accurate documentation on the assessment. |
02/15/2017
| Implemented |
| 6400.181(e)(13)(ii) | Repeat 06/30/15- Individual # 1's 02/20/16 assessment did not include progress and growth in the area of 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. | Sunset Support Services will complete monthly reports to ensure that the progress and growth in the area of motor and communication skills will be complete and accurate documentation on the assessment. |
02/15/2017
| Implemented |
| 6400.181(e)(13)(iii) | Repeat 06/30/15- Individual # 1's 02/20/16 assessment did not include progress and growth in the area of 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. | Sunset Support Services will complete monthly reports to ensure that the progress and growth in the area of residential living will be complete and accurate documentation on the assessment. |
02/15/2017
| Implemented |
| 6400.181(e)(13)(iv) | Repeat 06/30/15- Individual # 1's 02/20/16 assessment did not include progress and growth in the area of 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. | Sunset Support Services will complete monthly reports to ensure that the progress and growth in the area of personal adjustment will be complete and accurate documentation on the assessment. |
02/15/2017
| Implemented |
| 6400.181(e)(13)(v) | Repeat 06/30/15- Individual # 1's 02/20/16 assessment did not include progress and growth in the area of 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. | Sunset Support Services will complete monthly reports to ensure that the progress and growth in the area of socialization will be complete and accurate documentation on the assessment. |
02/15/2017
| Implemented |
| 6400.181(e)(13)(vi) | Repeat 06/30/15- Individual # 1's 02/20/16 assessment did not include progress and growth in the area of 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. | Sunset Support Services will complete monthly reports to ensure that the progress and growth in the area of recreation will be complete and accurate documentation on the assessment. |
02/15/2017
| Implemented |
| 6400.181(f) | Repeat - 06/30/15- Individual # 1's 02/20/16 assessment was not sent to the Service coordinator within 30 days of the Individual Support Plan meeting held 11/23/15. The original meeting date was 11/03/16 | (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 will work closely with the SC to ensure documentation in completed in a timely manner. |
02/15/2017
| Implemented |
| 6400.183(5) | Repeat 06/30/15- Individual # 1 takes psychiatric medications and does not have a social, emotional and environemental needs plan in place. | 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. | A S.E.E.N. plan has been implemented. |
02/15/2017
| Implemented |
| 6400.183(6)(i) | Individual # 1's 05/31/16 Individual Support Plan (ISP) did not include an assessment to determine the causes or antecedents of behaviors warranting restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: An assessment to determine the causes or antecedents of the behavior. | Sunset Support Services program specialist will work with the BSC to implement a chart to document the causes/antecedents of the behavior. |
02/15/2017
| Implemented |
| 6400.183(6)(ii) | Individual # 1's 05/31/16 Individual Support Plan (ISP) did not include a protocol for addressing the underlying causes or antecedents of behaviors which led to the use of restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for addressing the underlying causes or antecedents of the behavior. | Sunset Support Services program specialist will work with the SC and BSC to ensure all documentation is implemented into the ISP. |
02/15/2017
| Implemented |
| 6400.183(6)(iii) | Individual # 1's 05/31/16 Individual Support Plan (ISP) did not include the method and timeline for eliminating the use of restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. | Sunset Support Services program specialist will work with the SC to ensure all documentation is implemented into the ISP. |
02/15/2017
| Implemented |
| 6400.183(6)(iv) | Individual # 1's 05/31/16 Individual Support Plan (ISP) did not include a protocol for intervention or redirection without utilizing restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following A protocol for intervention or redirection without utilizing restrictive procedures. | Sunset Support Services program specialist will work with the SC to ensure all documentation is implemented into the ISP. |
02/15/2017
| Implemented |
| 6400.186(c)(2) | Individual # 1's Indvidual Support Plan reviews dated 07/01/16 and 10/03/16 do not review current outcomes of coping, safety, social skills nor the restrictive behavior plan or refusal of treatment plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Sunset Support Services will be implementing a more detailed quarterly format to ensure all information that is needed is documented on. |
02/15/2015
| Implemented |
| 6400.193(b)(1) | Individual # 1's record did not containt documentation of what attempts were made to anticipate and de-escalate his/he rbehaviors using methods of intervention less intrusive than his/her restrictive procedures | For each incident requiring restrictive procedures: Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than restrictive procedures.
| Sunset Support Service CPI instructor will do a retraining of de-escalation and anticipate. This will include the proper documentation how to completely document this. |
02/15/2017
| Implemented |
| 6400.194(d) | Individual # 1's restrictive procedure review committee meeting minutes were not kept. | A written record of the meetings and activities of the restrictive procedure review committee shall be kept.
| Sunset Support Services will work directly with the BSC to ensure the needed documents are attained. |
02/15/2017
| Implemented |
| 6400.195(b) | Individual # 1's restrictive procedure plan was not developed and revised with the participation of the program specialist and individual direct care staff. | The restrictive procedure plan shall be developed and revised with the participation of the program specialist, the individual's direct care staff, the interdisciplinary team as appropriate and other professionals as appropriate.
| Sunset Support Services Program Specialist and direct care staff will work closely with the Behavior Specialist to develop and revise the restrictive plan. There will be a sign off sheet for documentation and training. |
02/15/2017
| Implemented |
| 6400.195(d) | Individual # 1's restrictive procedure plan was not signed by the chariperson on 2/10/16 and was not reviewed and signed by the program specialist. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| Sunset Support Services CEO will work closely with the HRC to ensure the needed documentation is completed to remain within compliance. |
02/15/2017
| Implemented |
| 6400.195(e)(4) | Individual # 1's restrictive procedure plan does not include the restraints listed on the 07/28/16 restrictive procedure documentation by Staff # 1. | The restrictive procedure plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used.
| Sunset Support Services will retrain all of the current staff on incident management. |
02/15/2017
| Implemented |
| 6400.196(d) | Documentation of training of Individual # 1's restrictive procedure plan did not include the description of the training and the training source. | Documentation of the training program provided, including the staff persons trained, dates of training, description of training and training source shall be kept.
| Sunset Support Services Program Specialist will ensure and oversee the restrictive procedure plan training policy and procedures to comply with the 6400 regulations. |
02/15/2017
| Implemented |
| 6400.205 | No records were available that documented Individual # 1's behaviors, interventions, dates and times of interventions, procedures followed or staff persons involved, duration of interventions, staff person who observed exclusion or the condition of the individual following removal of the restrictive procedure/intervention. | A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure shall be kept in the individual's record.
| Sunset Support Services will implement a specific training for all staff to ensure they are tracking and recording all detailed incidents to comply with the 6400 regulations. |
02/15/2017
| Implemented |
| 6400.213(11) | Repeat 06/30/15- Individual # 1's Individual Support Plan (ISP) dated 5/31/16 under know and do states that he/she is capable of having unlimited time in his home and community and staff are working with him/her to increase independence and learning to be accountable. Individual # 1's restrictive procedure indicates 2:1 staff ratio and 24/7 supervision at arms length. Individual # 1's ISP does not state that he/she has seasonal allergies. The 03/24/16 Annual physical and 2016 updated face sheet in program book indicate allergy. ISP states that Individual # 1 has a behavior plan but it is not restrictive. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Sunset Support Services Program Specialist will work closely with the Supports coordinator to ensure that all updates/revisions are in compliance. |
02/15/2017
| Implemented |