| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The agency is Individual # 2's representative payee and there was no record of withdrawals and deposits. | 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. | Commonwealth Supportive Services has compiled all transaction records that show withdrawals and deposits for individual #2. Starting November 1st 2016, for individuals/participants of which Commonwealth Supportive Services is rep ¿payee, all financial transactions will be recorded in a ledger. The ledger will show records of withdrawals, deposits and balance. Finance personnel will ensure that every individual signs the ledger every time they receive money from Commonwealth Supportive Services. |
11/22/2016
| Implemented |
| 6400.22(e)(3) | Individual # 2 receives the remaining balance of the social security payment totaling $248.64 each month and the agency did not have receipts for June and July of 2016. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Receipts for June and July of 2016 signed by individual/participant #2 were given to state inspector Dina Scarci during the physical site inspection for review. She reviewed them. Starting November 1st 2016, all transactions, for individuals/participants of which Commonwealth Supportive Services is rep ¿payee, will be recorded in a ledger. Finance personnel will ensure that every individual signs the ledger every time they receive money from Commonwealth Supportive Services. [Finance personnel will retain receipt of all transactions and disbursement paid out to all program participants DS 12/29/2016] See attached receipts. (See attachment 11) |
11/22/2016
| Implemented |
| 6400.46(a) | Repeated Violation-(01/28/2016)
Staff # 1's date of hire was 08/20/2016 and orientation was completed on 09/13/2016.
Staff # 2's date of hire was 04/13/201/6 and orientation was completed on 04/23/2016.
| The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Regulation states that the home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Staff #1 received orientation to the home on 9/13/2016 @ 1pm and started working with the individuals/participants in the home on 9/19/2016. Staff #1 did not work with the individuals in the home until orientation to the home was completed.
Staff # 2's date of hire was 04/23/201/6 and orientation was completed on 04/23/2016.
Commonwealth Supportive Services Quality Assurance Personnel and Administrator will continue to ensure that all staff receive the required trainings upon their dates of hire before working with the individuals. |
11/22/2016
| Implemented |
| 6400.46(f) | Repeated Violation-(01/28/2016)Staff # 2's date of hire was 04/13/2016 and general fire safety training was completed on 04/23/2016. | 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. | Staff # 2's date of hire was 04/23/201/6 and general fire safety training was completed on 04/23/2016.Commonwealth Supportive Services Quality Assurance Personnel and Administrator will continue to ensure that all staff receive the required trainings upon their dates of hire before working with the individuals. [Commonwealth Supportive Service coordinator/trainer will ensure all staff are trained in general fire safety prior to working with individuals DS 12/29/2016.] |
11/22/2016
| Implemented |
| 6400.46(h) | Repeated Violation-(01/28/2016)Staff # 3's date of hire was 08/24/2016 and there was no documentation of training in first aid techniques. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. | Staff #3 was trained in CPR/First Aid on 10/07/2016. Moving forward, Commonwealth Supportive Services Quality Assurance Personnel and Administrator will ensure that all prospective employees receive training in First Aid/CPR before working with the Individuals/participants.[Quality Assurance Personnel and Administrator will develop a new hire checklist ensuring that all required trainings are completed as outlined in the regulations within the prescribed timeframes within 15 days receipt of this plan of correction. Additionally, this new hire checklist will be completed for all new hires within 30 days receipt of this plan of correction DD 11.28.16] |
11/22/2016
| Implemented |
| 6400.141(c)(1) | Individual # 2's physical examination dated 05/12/2016 did not document a medical history review. | The physical examination shall include: A review of previous medical history. | Individual/Participant #2 physical was taken to the PCP on 10/11/2016 to include review of previous medical history. Annual Physical has been updated. Moving forward, Commonwealth Supportive Services Nurse will review all Individual/Participant Physicals to ensure that they meet the requirements of 55 PA Code Chapter 6400.141. See attached updated physical. (See Attachment 11) |
11/22/2016
| Implemented |
| 6400.141(c)(10) | Individual # 1's physical examination dated 05/12/2016 did not document if the individual was free of communicable disease.
Individual # 2's physical examination dated 05/12/2016 did not document if the individual was free of communicable disease.
| The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual/Participant #1 and #2 physicals were taken to the PCP on 10/11/2016 to include that the individuals were free of communicable diseases. Annual Physical has been updated. Moving forward, Commonwealth Supportive Services Nurse will review all Individual/Participant Physicals to ensure that they meet the requirements of 55 PA Code Chapter 6400.141. See attached updated physical. (See Attachment 11) |
11/22/2016
| Implemented |
| 6400.141(c)(11) | Individual # 2's physical examination dated 05/12/2016 did not health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Individual/Participant #2 physical was taken to the PCP on 10/11/2016 to include the individual¿s health maintenance needs. Annual Physical has been updated. Moving forward, Commonwealth Supportive Services Nurse will review all Individual/Participant Physicals to ensure that they meet the requirements of 55 PA Code Chapter 6400.141. See attached updated physical. (See Attachment 11) |
11/22/2016
| Implemented |
| 6400.141(c)(12) | Individual # 2's physical examination dated 05/12/2016 did not document the individual's physical limitations. | The physical examination shall include: Physical limitations of the individual. | Individual/Participant #2 physical was taken to the PCP on 10/11/2016 to include the individual's physical limitations. Annual Physical has been updated. Moving forward, Commonwealth Supportive Services Nurse will review all Individual/Participant Physicals to ensure that they meet the requirements of 55 PA Code Chapter 6400.141. See attached updated physical. (See Attachment 11). |
11/22/2016
| Implemented |
| 6400.141(c)(13) | Individual # 2's physical examination dated 05/12/2016 did not document allergies | The physical examination shall include: Allergies or contraindicated medications. | Individual/Participant #2 physical was taken to the PCP on 10/11/2016 to include the individual's allergies. Annual Physical has been updated. Moving forward, Commonwealth Supportive Services Nurse will review all Individual/Participant Physicals to ensure that they meet the requirements of 55 PA Code Chapter 6400.141. See attached updated physical. (See Attachment 11) |
11/22/2016
| Implemented |
| 6400.141(c)(14) | Individual # 2's physical examination dated 05/12/2016 did not document 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. | Individual/Participant #2 physical was taken to the PCP on 10/11/2016 to include medical information pertinent to diagnosis and treatment in case of an emergency. Annual Physical has been updated. Moving forward, Commonwealth Supportive Services Nurse will review all Individual/Participant Physicals to ensure that they meet the requirements of 55 PA Code Chapter 6400.141. See attached updated physical. (See Attachment 11) |
11/22/2016
| Implemented |
| 6400.141(c)(15) | Individual # 2's physical examination dated 05/12/2016 did not document instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | Individual/Participant #2 physical was taken to the PCP on 10/11/2016 to include Special instructions for the individual¿s diet. Annual Physical has been updated. Moving forward, Commonwealth Supportive Services Nurse will review all Individual/Participant Physicals to ensure that they meet the requirements of 55 PA Code Chapter 6400.141. See attached updated physical. (See Attachment 11) |
11/22/2016
| Implemented |
| 6400.143(a) | Individual # 2 refused a gynecological exam and a mammogram and there was not documentation of a desensitization plan. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A refusal plan and tracking form has been developed by the Program Specialist. All staff have been trained on Individual #2 refusal plan. Moving forward, the Program Specialist, Direct Support Staff and Nurse will implement the refusal plan to continually educate Individual/Participant # 2 on the importance of completing their gynecological exams, mammograms and all other medical appointments. (See Attachment 10) |
11/22/2016
| Implemented |
| 6400.151(a) | Repeated Violation-(01/28/2016)Staff # 1's date of hire was 08/30/2016 and there was no documentation of a physical examination.
Staff # 3's dated of hire was 08/24/2016 and the physical examination was dated 09/14/2016.
| 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff #1 Physical has been updated. Commonwealth Supportive Services has modified its Staff qualification and Hiring Policy. All staff physicals have been updated and current. Moving Forward, Quality Assurance Personnel and Administrator will utilize pre-employment checklist to ensure that prospective employees have all required documentation including a physical examination within 12 months prior to employment and annually thereafter. ( See attachment 8) |
11/22/2016
| Implemented |
| 6400.151(c)(2) | Staff # 3's physical examination dated 09/14/2016 did not document tuberculin skin testing. | 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. | All staff physicals have been updated and current. Moving Forward, Quality Assurance Personnel and Administrator will utilize pre-employment checklist to ensure that prospective employees have all required documentation including a physical examination within 12 months prior to employment and annually thereafter. Physicals 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. (See attachment 9) |
11/22/2016
| Implemented |
| 6400.181(c) | Individual # 1's assessment dated 12/09/2015 did not document the basis of the assessment.
Individual # 2's assessment dated 12/09/2015 did not document the basis of the assessment.
| The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Commonwealth Supportive Services has hired a new Program Specialist. A new Assessment was completed for Individual/Participant 1 on 10/03/2016 and Individual/Participant 2 Assessment was completed on 10/05/2016. Assessments completed included basis of the assessments (Individual Interviews, Staff Interviews, ISP and Family Interviews). Moving forward, Program Specialist will complete all assessments on time and will meet all requirements as per 55 PA Code Chapter 6400.181. Quality Assurance will review all individual files to ensure that assessments are completed and meet the requirements of 55 PA code chapter 6400.181 (c). (See attachment 6). |
11/22/2016
| Implemented |
| 6400.181(e)(2) | Individual # 1's assessment dated 12/09/2015 did not document likes, dislikes or interests.
Individual # 2's assessment dated 12/09/2015 did not document likes, dislikes or interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Commonwealth Supportive Services has hired a new Program Specialist. A new Assessment was completed for Individual/Participant 1 on 10/03/2016 and Individual/Participant 2 Assessment was completed on 10/05/2016. Assessments completed documented likes, dislikes or interests. Moving forward, Program Specialist will complete all assessments on time and will meet all requirements as per 55 PA Code Chapter 6400.181. Quality Assurance will review all individual files to ensure that assessments are completed and meet the requirements of 55 PA code chapter 6400.181 (c). (See attachment 6). |
11/22/2016
| Implemented |
| 6400.181(e)(5) | Individual # 2's assessment dated 12/09/2015 did not document the ability to self-administer medication | The assessment must include the following information: The individual's ability to self-administer medications. | Commonwealth Supportive Services has hired a new Program Specialist. A new Assessment was completed for Individual/Participant 1 on 10/03/2016 and Individual/Participant 2 Assessment was completed on 10/05/2016. Assessments completed documented the ability to self-administer medication. Moving forward, Program Specialist will complete all assessments on time and will meet all requirements as per 55 PA Code Chapter 6400.181. Quality Assurance will review all individual files to ensure that assessments are completed and meet the requirements of 55 PA code chapter 6400.181 (c). (See attachment 6). |
11/22/2016
| Implemented |
| 6400.181(e)(10) | Individual # 1's assessment dated 12/09/2015 did not document a lifetime medical history.
Individual # 2's assessment dated 12/09/2015 did not document a lifetime medical history.
| The assessment must include the following information: A lifetime medical history. | Commonwealth Supportive Services has hired a new Program Specialist. A new Assessment was completed for Individual/Participant 1 on 10/03/2016 and Individual/Participant 2 Assessment was completed on 10/05/2016. The aforementioned individuals/participants do not have documentation on their past medical history. Program Specialist and Site Manager are in the process of gathering past medical records in order to compile a comprehensive and accurate lifetime medical history. Program Specialist will complete Lifetime medical history for Individuals/participant 1 and 2 by 11/15/2016. Moving forward, Program Specialist will complete all assessments on time and will include a lifetime medical history and meet all requirements as per 55 PA Code Chapter 6400.181. Quality Assurance will review all individual files to ensure that assessments are completed and meet the requirements of 55 PA code chapter 6400.181 (c). (See attachment 6). |
11/22/2016
| Implemented |
| 6400.181(e)(13)(vi) | The agency is Individual # 2's representative payee and Individual # 2 receives $ 248.64 each month as personal spending money. Individual # 2's assessment dated 12/09/2016 does not document the amount of money they can manage without assistance. | 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 was completed for Individual/Participant 2 on 10/05/2016. Individual/Participant requests to receive the remainder of their money after paying room and board. Assessments completed documented the individual/participant ability to handle up to one thousand dollars. Moving forward, Program Specialist will complete all assessments on time and will meet all requirements as per 55 PA Code Chapter 6400.181. Quality Assurance will review all individual files to ensure that assessments are completed and meet the requirements of 55 PA code chapter 6400.181 (c). (See attachment 6). |
11/22/2016
| Implemented |
| 6400.181(f) | There is no documentation Individual # 1 and Individual # 2's assessment dated 12/09/2015 was sent to team members prior to the ISP meeting held on 06/08/2016. | (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).
| Individuals/Participants #1 and #2 ISP¿s were not held on 06/08/2016. ISP meetings for Individual/Participants 1 and 2 was held on October 17th, 2016. ISP invite letters were received on 10/03/2016 and Assessments were sent on 10/05/2016. SC informed Program Specialist that ISP meeting had to be held in October instead of December which was the appropriate time to hold the ISP meeting from the previous ISP. Moving Forward, the program specialist will 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). Quality Assurance will review all individual files to ensure that assessments are sent to plan team members after being updated and at least 30calendar days prior to scheduled ISP Meeting. (See attachment 7) |
11/22/2016
| Implemented |
| 6400.183(5) | Individual # 1 is prescribed medication to treat psychiatric diagnoses and there was no documentation of a social, emotional or environmental plan. | 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. | Commonwealth Supportive Services has hired a new Program Specialist. A new Assessment was completed for Individual 1 on 10/03/2016. As part of the assessment, a social, emotional and environmental plan was developed for the Individual/participant. Moving forward, the Program Specialist will develop a protocol to address the social, emotional and environmental needs of an individual/participant who is prescribed medications to treat symptoms of a diagnosed psychiatric illness. All staff have been trained on the social, emotional environmental plan. (See attachment 5) |
11/22/2016
| Implemented |
| 6400.185(b) | There was no documentation of the methodology used to track progress towards Individual # 1's outcome of independence as identified in the ISP effective 12/18/2015.
There was no documentation of the methodology used to track progress towards Individual # 2's outcome of independence as identified in the ISP effective 01/13/2016.
| The ISP shall be implemented as written. | Individual # 1 has a methodology to track progress towards outcome of independence (Hygiene, ADL and Money management). Program Specialist will record data for goals in all quarterly reports to determine if progress is being made. State inspector Dina Scarci was shown goals and tracking form while conducting her site visit.
Program Specialist has developed goals towards independence and a methodology to track progress for Individual/Participant #2 as identified in the ISP. Program Specialist will record data for goals in all quarterly reports to determine if progress is being made. Moving forward, Program Specialist, supervised by the Executive Director, will develop plans/goals geared towards Individual/Participant outcomes as identified in their respective ISP¿s and will implement all ISP¿s as written. Site Manager will review all goals and tracking forms weekly to ensure that the goals are implemented as per the ISP. (See attachment 4) |
11/22/2016
| Implemented |
| 6400.186(a) | Individual # 1's record did not document three month ISP review documentation.
Individual # 2's most recent three month ISP review documentation was dated 10/20/2015-01/20/2015 and their date of admission was 12/09/2015.
| The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Plan of Correction: Commonwealth Supportive Services has hired a new program Specialist who will complete all ISP quarterly reviews. Moving forward, Program Specialist will complete all quarterly ISP reviews in a timely manner and will review it with the individual/participant. All reviews will be properly documented and will accurately include dates of periods being covered, ISP outcomes and signatures of the individual/participant. CSS Program Specialist will complete a quarterly review for the last quarter (covering August, September and October) by 11/05/2016 for both Individuals/Participants 1 & 2. Quality Assurance Personnel will review all individual/participant files to ensure that quarterly reviews are completed in accordance with 55PA Code 6400.186(a) |
11/22/2016
| Implemented |
| 6400.186(c)(1) | Individual # 1 did not have monthly review documentation for June, July, and August of 2016.
Individual # 2 did not have monthly review documentation for May, June, July, and August of 2016.
| The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | Plan of Correction: Commonwealth Supportive Services has hired a new program Specialist who will complete all monthly reviews. CSS Program Specialist completed monthly reports for all individuals for the month on September on 10/03/2016. Moving forward, Program Specialist will complete all monthly reviews in a timely manner. Quality Assurance Personnel will review all individual/participant files to ensure that monthly reviews are completed in accordance with 55PA Code 6400.186(c)(1). (See attachment 3) |
11/22/2016
| Implemented |
| 6400.217 | Individual # 1 and Individual # 2's record did not have a written consent to release of information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| As of 10/3/2016, Commonwealth Supportive Services Administrator and Quality Assurance Personnel have created a release of information consent form and presented it to all participants. All individuals/participants signed the consent. Moving forward, upon admission to Commonwealth Supportive Services, all individuals/participants will be required to sign a consent to release information. Quality assurance will create an admission checklist which will include signing the consent to release information. QA will review admission packets to ensure compliance at admission and annually thereafter. (See attachment 1) |
11/22/2016
| Implemented |
| Article X.1007 | Repeated Violation-(01/28/2016)
Commonwealth Supportive Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff # 1¿s date of hire was 08/20/2016 and the FBI clearance was completed on 03/31/2015. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Staff #1 indicated on their application that they have been a resident of PA for more than two years. The FBI Clearance was filed in error. It has been removed for the staff¿s file. Moving Forward, Quality Assurance Personnel and Administrator will utilize pre-employment checklist to ensure that prospective employees have all required documentation. Commonwealth Supportive Services only runs/requires FBI clearance for persons that have not been a resident of PA for over two years |
11/22/2016
| Implemented |