| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(f) | Staff #1 completed fire safety training on 8/22/16 and not again until 9/5/17. | Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f). | 1. Who/What/When/How
a. Vista establishes 9/1/year through 8/31/year as its annual training year and had ensured all staff including the program specialist received training from a firesafety expert within this timeframe. However, it is now understood the training must occur within 365 days of its previous occurrence regardless of the defined annual training year. Training plans have been updated to ensure the next occurrence of annual firesafety occurs within 365 days of the most recently provided training that occurred in September of 2017.
2. Long Term Preventative Plan
a. A certification expiration log has electronically been submitted in Vista¿s employee portal for the program specialist and other relevant staff to generate automatic notifications in advance of due dates. An annual training plan has been developed establishing dates for training that ensure compliance. A firesafety expert has been filmed providing training to serve as a backup in the event the individual is unable to attend in person.
3. Training
a. The program specialist and training coordinator have reviewed regulations associated with training requirements completed on 11/2/17.
4. Evidence
a. The annual training plan has been updated to include specific language around firesafety training along with others being required within 365 days of previous occurrence.
5. Attachment Names
a. Annual Training Plan notification titled ¿Attachment 11 ¿ Annual Training Plan¿ |
11/10/2017
| Implemented |
| 2380.111(a) | Individual #2 had a physical completed on 4/7/17. Previous physical in record was not dated, therefore unable to determine when it was completed. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 1. Who/What/When/How
a. All consumers currently have annual physical examinations on file but had fields that the doctor failed to score. The program specialist with support from an operation¿s team member will build a review system into place to ensure all fields on annual physical exams are properly completed and where not the case contact the primary care physician (or appropriate party) to acquire necessary information. The program specialist and operation¿s team member will internally audit all physical exams and seek additional information where applicable with target date 12/31/17 for all individuals.
2. Long Term Preventative Plan
a. An operation¿s team member will internally audit consumer physical exams to ensure fully completed and report back to the program specialist and director of adult employment services (CEO) for remediation when necessary.
3. Training
a. The program specialist and operation¿s team member were trained in regulations associated with physical examination requirements on 11/2/17.
4. Evidence
a. Updated physical examinations were secured for the two audited consumers and will be available 11/10/17. All additional individual physical examinations can be available as requested as of 12/31/17.
5. Attachment Names
a. Annual Physical Exam #1 titled ¿Attachment 9 ¿ Annual Physical Exam 1¿
b. Annual Physical Exam #2 titled ¿Attachment 10 ¿ Annual Physical Exam 2¿ |
12/31/2017
| Implemented |
| 2380.111(c)(1) | Individual #2's physical dated 4/7/17 did not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | 1. Who/What/When/How
a. All consumers currently have annual physical examinations on file but had fields including previous medical history that the doctor failed to score. The program specialist with support from an operation¿s team member will build a review system into place to ensure all fields on annual physical exams are properly completed and where not the case contact the primary care physician (or appropriate party) to acquire necessary information and pull previous medical history from other individual records such as the ISP. The program specialist and operation¿s team member will internally audit all physical exams and seek additional information where applicable with target date 12/31/17 for all individuals.
2. Long Term Preventative Plan
a. An operation¿s team member will internally audit consumer physical exams to ensure fully completed and report back to the program specialist and director of adult employment services (CEO) for remediation when necessary.
3. Training
a. The program specialist and operation¿s team member were trained in regulations associated with physical examination requirements on 11/2/17.
4. Evidence
a. Updated physical examinations were secured for the two audited consumers and will be available 11/10/17. All additional individual physical examinations can be available as requested as of 12/31/17.
5. Attachment Names
a. Annual Physical Exam #1 titled ¿Attachment 9 ¿ Annual Physical Exam 1¿
b. Annual Physical Exam #2 titled ¿Attachment 10 ¿ Annual Physical Exam 2¿ |
12/31/2017
| Implemented |
| 2380.111(c)(6) | Individual #2's physical dated 4/7/17 did not include communicable disease status. It was left blank. | The physical examination shall include: Specific precautions that shall be taken if the individual 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, to prevent the spread of the disease to other individuals. | 1. Who/What/When/How
a. All consumers currently have annual physical examinations on file but had fields including precautions if the individual has a communicable disease that the doctor failed to score. The program specialist with support from an operation¿s team member will build a review system into place to ensure all fields on annual physical exams are properly completed and where not the case contact the primary care physician (or appropriate party) to acquire necessary information. The program specialist and operation¿s team member will internally audit all physical exams and seek additional information where applicable with target date 12/31/17 for all individuals.
2. Long Term Preventative Plan
a. An operation¿s team member will internally audit consumer physical exams to ensure fully completed and report back to the program specialist and director of adult employment services (CEO) for remediation when necessary.
3. Training
a. The program specialist and operation¿s team member were trained in regulations associated with physical examination requirements on 11/2/17.
4. Evidence
a. Updated physical examinations were secured for the two audited consumers and will be available 11/10/17. All additional individual physical examinations can be available as requested as of 12/31/17.
5. Attachment Names
a. Annual Physical Exam #1 titled ¿Attachment 9 ¿ Annual Physical Exam 1¿
b. Annual Physical Exam #2 titled ¿Attachment 10 ¿ Annual Physical Exam 2¿ |
12/31/2017
| Implemented |
| 2380.111(c)(10) | Individual #1's physical dated 6/8/17 and Individual #2's physical dated 4/7/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 1. Who/What/When/How
a. All consumers currently have annual physical examinations on file but had fields including information pertinent to diagnosis and treatment in case of an emergency the doctor failed to score. The program specialist with support from an operation¿s team member will build a review system into place to ensure all fields on annual physical exams are properly completed and where not the case contact the primary care physician (or appropriate party) to acquire necessary information. The program specialist and operation¿s team member will internally audit all physical exams and seek additional information where applicable with target date 12/31/17 for all individuals.
2. Long Term Preventative Plan
a. An operation¿s team member will internally audit consumer physical exams to ensure fully completed and report back to the program specialist and director of adult employment services (CEO) for remediation when necessary.
3. Training
a. The program specialist and operation¿s team member were trained in regulations associated with physical examination requirements on 11/2/17.
4. Evidence
a. Updated physical examinations were secured for the two audited consumers and will be available 11/10/17. All additional individual physical examinations can be available as requested as of 12/31/17.
5. Attachment Names
a. Annual Physical Exam #1 titled ¿Attachment 9 ¿ Annual Physical Exam 1¿
b. Annual Physical Exam #2 titled ¿Attachment 10 ¿ Annual Physical Exam 2¿ |
12/31/2017
| Implemented |
| 2380.111(c)(11) | Individual #1's physical dated 6/8/17 did not include special diet instructions. It was left blank. | The physical examination shall include: Special instructions for an individual's diet. | 1. Who/What/When/How
a. All consumers currently have annual physical examinations on file but had fields including special instructions for an individual¿s diet that the doctor failed to score. The program specialist with support from an operation¿s team member will build a review system into place to ensure all fields on annual physical exams are properly completed and where not the case contact the primary care physician (or appropriate party) to acquire necessary information. The program specialist and operation¿s team member will internally audit all physical exams and seek additional information where applicable with target date 12/31/17 for all individuals.
2. Long Term Preventative Plan
a. An operation¿s team member will internally audit consumer physical exams to ensure fully completed and report back to the program specialist and director of adult employment services (CEO) for remediation when necessary.
3. Training
a. The program specialist and operation¿s team member were trained in regulations associated with physical examination requirements on 11/2/17.
4. Evidence
a. Updated physical examinations were secured for the two audited consumers and will be available 11/10/17. All additional individual physical examinations can be available as requested as of 12/31/17.
5. Attachment Names
a. Annual Physical Exam #1 titled ¿Attachment 9 ¿ Annual Physical Exam 1¿
b. Annual Physical Exam #2 titled ¿Attachment 10 ¿ Annual Physical Exam 2¿ |
12/31/2017
| Implemented |
| 2380.173(1)(i) | Individual #1's and Individual #2's record did not contain admission dates. | Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number. | 1. Who/What/When/How
a. The intake individual demographic sheet was updated to include ¿date of admission.¿ All other required information is currently on the intake demographic sheet and updated as relevant including name, sex, birthdate and social security [if offered].¿ The program specialist in conjunction with operation¿s team member will update all demographic sheets to include date of admission (target date 12/31/17) and use the new template for new individuals to the program effective immediately (11/10/17).
2. Long Term Preventative Plan
a. The operation¿s team member will internally audit demographic documents to ensure proper information is included and accurate.
3. Training
a. The program specialist and operation¿s team member received training on proper demographic documentation on 11/2/17.
4. Evidence
a. A completed demographic sheet with inclusion of date of admission will be provided for each of the two individuals audited at the recent on-site inspection by 11/10/17. Demographic sheets for all other served individuals can be available at request after 12/31/17.
5. Attachment Names
a. Demographic Sheet #1 titled ¿Attachment 5 ¿ Demographic Sheet 1¿
b. Demographic Sheet #2 titled ¿Attachment 6 ¿ Demographic Sheet 2¿ |
12/31/2017
| Implemented |
| 2380.173(1)(ii) | Individual #1 and Individual #2's record did not contain information regarding identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | 1. Who/What/When/How
a. The program specialist in conjunction with operation¿s team member will update all demographic sheets to ensure sections are populated that include race, height, weight, color of hair, color of eyes and identifying marks (target date 12/31/17) and ensure for all new individuals to the program all fields are scored effective immediately (11/10/17).
2. Long Term Preventative Plan
a. The operation¿s team member will internally audit demographic documents to ensure proper information is included and accurate.
3. Training
a. The program specialist and operation¿s team member received training on proper demographic documentation on 11/2/17.
4. Evidence
a. A completed demographic sheet with inclusion of race, height, weight, color of hair, color of eyes and identifying marks will be provided for each of the two individuals audited at the recent on-site inspection by 11/10/17. Demographic sheets for all other served individuals can be available at request after 12/31/17.
5. Attachment Names
a. Demographic Sheet #1 titled ¿Attachment 5 ¿ Demographic Sheet 1¿
b. Demographic Sheet #2 titled ¿Attachment 6 ¿ Demographic Sheet 2¿ |
12/31/2017
| Implemented |
| 2380.173(1)(iv) | Individual #2's record did not contain information regarding religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | 1. Who/What/When/How
a. The program specialist in conjunction with operation¿s team member will update all demographic sheets to ensure sections are populated that includes religious affiliation (target date 12/31/17) and ensure for all new individuals to the program all fields are scored effective immediately (11/10/17).
2. Long Term Preventative Plan
a. The operation¿s team member will internally audit demographic documents to ensure proper information is included and accurate.
3. Training
a. The program specialist and operation¿s team member received training on proper demographic documentation on 11/2/17.
4. Evidence
a. A completed demographic sheet with inclusion of religious affiliation will be provided for each of the two individuals audited at the recent on-site inspection by 11/10/17. Demographic sheets for all other served individuals can be available at request after 12/31/17.
5. Attachment Names
a. Demographic Sheet #1 titled ¿Attachment 5 ¿ Demographic Sheet 1¿
b. Demographic Sheet #2 titled ¿Attachment 6 ¿ Demographic Sheet 2¿ |
12/31/2017
| Implemented |
| 2380.181(d) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields ¿ completed 11/2/17. The program specialist will sign and date all assessments. As assessments are updated on the new template the program specialist will sign and date. All ongoing completion of assessments will include the signature of the program specialist and date.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(3)(i) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not include current level of performance and progress in the following areas: 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including acquisition of functional skills ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(4) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s need for supervision. | The assessment must include the following information: The individual¿s need for supervision. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including the individual¿s need for supervision ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(5) | Individual #2's assessment completed 2/21/17 did not include the following information: The individual¿s ability to self-administer medications. | The assessment must include the following information: The individual¿s ability to self-administer medications. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including individual¿s ability to self-administer medications ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(6) | Individual #2's assessment completed 2/21/17 did not include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including the individual¿s ability to safely use or avoid poisonous materials, when in their presence ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(7) | Individual #2's assessment completed 2/21/17 did not 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. | 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including the individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources, which exceed 120 degrees Fahrenheit and are not insulated ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(8) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including the individual¿s ability to evacuate in the event of a fire ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(10) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: A lifetime medical history. | The assessment must include the following information: A lifetime medical history. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including a lifetime medical history ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(13)(i) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including progress over the last 365 days in the area of health ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual's progress over the last 365 calendar days and current level in the following areas: 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including progress over the last 365 days in the areas of motor and communication skills ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including progress over the last 365 days in the area of personal adjustment ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including progress over the last 365 days in the area of socialization ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including progress over the last 365 days in the area of recreation ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's assessment completed 8/25/17 and Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: 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. | 1. Who/What/When/How
a. The assessment template has been updated to include all required fields including progress over the last 365 days in the area of community-integration ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(e)(14) | Individual #2's assessment completed 2/21/17 did not contain the following information: The individual¿s knowledge of water safety and ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | to swim.
1. Who/What/When/How
a. The assessment template has been updated to include all required fields including the individual¿s knowledge of water safety and ability to swim ¿ completed 11/2/17. The program specialist will be updating all assessments onto the new template with 11/10/17 the target date for completion of first two assessments and 12/31/17 for all remaining assessments.
2. Long Term Preventative Plan
a. An operation¿s team member and director of adult employment services (CEO) will review completed assessments before dissemination and provide remediated training to the program specialist as applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. Annual assessments will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer annual assessments will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.181(f) | No dates were present in the records of Individual #1 or Individual #2 to document that the assessments were provided to the SC or plan lead, 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). | The program specialist shall provide the assessment to the SC or plan lead, 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). | 1. Who/What/When/How
a. The program specialist will complete the updated annual assessment form for all individuals and disseminate to the SC and plan team members 30 days prior to an ISP meeting here ongoing (11/10/17). The program specialist will use scheduling software to serve as reminders for occurrences of ISP meetings and corresponding annual assessment due dates effective immediately.
2. Long Term Preventative Plan
a. An operation¿s team member will monitor accurate use of scheduling software and compliance disseminating the annual assessment within required timelines. The director of adult employment services (CEO) will spot check the work of the program specialist and remediate training when applicable.
3. Training
a. The program specialist and operation¿s team member were trained on the regulations associated with proper completion of annual assessments on 11/2/17.
4. Evidence
a. The Annual Assessment Protocol includes language specifying the regulation to have the annual assessment disseminated at least 30 days prior to the ISP meeting.
5. Attachment Names
a. Annual Assessment Protocol titled ¿Attachment 4 ¿ Annual Assessment Protocol¿ |
12/31/2017
| Implemented |
| 2380.183(5) | Individual #2's record did not 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 ISP, including annual updates and revisions under § 2380.186 (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. | 1. Who/What/When/How
a. The program specialist will ensure SEEN plans are sent to the SC with request to be included in the ISP. The program specialist will ensure SEEN plans are updated if any medication is altered or added that serves intent of treating psychiatric behaviors. The program specialist will update and disseminate all SEEN plans that currently are not present in ISPs by 12/31/17.
2. Long Term Preventative Plan
a. An operation¿s team member and the director of adult employment services (CEO) will monitor compliance of the program specialist at dissemination of SEEN plans through review of ISP documents and follow along supervision of the staff member.
3. Training
a. The program specialist and operation¿s team member will be trained in the protocol associated with SEEN plans by 12/31/17 if not prior (delayed date due to unpredictability of program specialist¿s paternity leave during which time the CEO will be covering responsibilities).
4. Evidence
a. Protocol updated to reflect regulatory requirement of sending SEEN plans to the SC with request to include in the ISP.
5. Attachment Names
a. SEEN plan protocol titled ¿Attachment 3 ¿ SEEN plan protocol¿ |
12/31/2017
| Implemented |
| 2380.186(a) | Individual #2's ISP review covering the period of 6/6/17 to 9/4/17 was completed on 10/18/17. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | 1. Who/What/When/How
a. The program specialist will use a scheduling system to ensure all consumers have ISP reviews at minimum every 3-months from their ISP date effective immediately, 11/10/17. The program specialist will update all current consumer records that are out of compliance requiring an ISP review with completion date of 12/31/17.
2. Long Term Preventative Plan
a. Program specialist¿s work will be monitored by both an operation¿s team member and the director of adult employment services (CEO) on a monthly basis to ensure scheduling system is effective and ISP reviews are occurring at least every 3 months or greater if needs of the individual change as specified in the ISP.
3. Training
a. The program specialist and operation¿s team member were trained in all areas associated with properly conducting ISP reviews ¿ conducted 11/2/17.
4. Evidence
a. ISP reviews will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer ISP review records will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.186(b) | ISP reviews were not signed by the program specialst or individual in Individual #1 and in Individual #2's records. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | 1. Who/What/When/How
a. The program specialist will discuss the updated ISP reviews with individuals, with both the program specialist and individual to sign and date upon completion. This will occur for the two consumers sampled during the audit by 11/10/17 and all other applicable consumers by 12/31/17. The ISP review document was updated 11/2/17 to clearly specify location of the signature and dates.
2. Long Term Preventative Plan
a. Program specialist¿s work will be monitored by both an operation¿s team member and the director of adult employment services (CEO) on a monthly basis to ensure ISP review records are signed and dated.
3. Training
a. The program specialist and operation¿s team member were trained in all areas associated with properly conducting ISP reviews ¿ conducted 11/2/17.
4. Evidence
a. ISP reviews will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer ISP review records will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.186(c)(1) | Individual #2's ISP review did not 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 facility licensed under this chapter. | 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 facility licensed under this chapter. | 1. Who/What/When/How
a. The ISP review template was updated to ensure it includes all necessary components ¿ completed 11/2/17 and will be used ongoing for all consumers within licensed programming. The program specialist will update all licensed consumer documents with first two completed by 11/10/17 and all additional records updated by 12/31/17. The ISP review template includes a section to review progress towards ISP outcomes during the 3-month period.
2. Long Term Preventative Plan
a. Program specialist¿s work will be monitored by both an operation¿s team member and the director of adult employment services (CEO) following completion to ensure all essential information is included.
3. Training
a. The program specialist and operation¿s team member were trained in all areas associated with properly conducting ISP reviews ¿ conducted 11/2/17.
4. Evidence
a. ISP reviews will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer ISP review records will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.186(c)(2) | Individual #2's ISP review did not include the following: A review of each section of the ISP specific to the facility licensed under this chapter (review of SEEN plan, plan for supervision, review of behavior plan). | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | 1. Who/What/When/How
a. The ISP review template was updated to ensure it includes all necessary components ¿ completed 11/2/17 and will be used ongoing for all consumers within licensed programming. The program specialist will update all licensed consumer documents with first two completed by 11/10/17 and all additional records updated by 12/31/17. The ISP review template includes a section to review all sections of the ISP specific to the facility licensed under this chapter.
2. Long Term Preventative Plan
a. Program specialist¿s work will be monitored by both an operation¿s team member and the director of adult employment services (CEO) following completion to ensure all essential information is included.
3. Training
a. The program specialist and operation¿s team member were trained in all areas associated with properly conducting ISP reviews ¿ conducted 11/2/17.
4. Evidence
a. ISP reviews will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer ISP review records will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.186(d) | No date was documented in Individual #2's record to indicate when the ISP review was sent to team members. Documentation in Individual #1's record indicated the ISP review was not sent to all team members (SC, and residential provider). | 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. | 1. Who/What/When/How
a. The program specialist will use scheduling tools to serve as reminders that all ISP review documentation must be sent to the SC and plan team members within 30 days after the ISP review meeting. A cover sheet has been added to the ISP review template to identify names, contact information of all recipients and date of dissemination. The program specialist will disseminate updated ISP reviews as completed with latest date of last dissemination 1/30/18 which is exactly 30 days after date of POC completion.
2. Long Term Preventative Plan
a. The operation¿s team member will maintain a spreadsheet tracking dissemination of ISP review documentation. The director of adult employment services (CEO) will review on a monthly basis to ensure appropriate action is taken by the program specialist.
3. Training
a. The program specialist and operation¿s team member were trained in all areas associated with properly conducting ISP reviews ¿ conducted 11/2/17.
4. Evidence
a. ISP reviews will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer ISP review records will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| 2380.186(e) | An option to decline the ISP review documentation was not present in Individual #2's record. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | 1. Who/What/When/How
a. The program specialist will inform all plan team members of the option to decline the ISP review documentation at intake and ongoing at annual meetings. The program specialist will maintain communication with team members throughout the course of treatment should an individual change their mind and either want to or no longer want to receive the ISP review documentation. A cover sheet has been added to the ISP review template that indicates per team member interest or disinterest in receiving information. The program specialist will complete the cover sheet fully before dissemination. This template is in place effective now 11/10/17 and completed for two consumers. The cover sheet will be utilized for all ongoing ISP reviews including those to be updated leading to the POC date of 12/31/17.
2. Long Term Preventative Plan
a. The operation¿s team member and director of adult employment services (CEO) will ensure the checklist has been properly completed including notation of interest or disinterest of receiving ISP review documentation before dissemination and review any errors with the program specialist as a means of remediated training.
3. Training
a. The program specialist and operation¿s team member were trained in all areas associated with properly conducting ISP reviews ¿ conducted 11/2/17.
4. Evidence
a. ISP reviews will be provided for the two consumers selected at the on-site audit reflecting compliance with the regulation to be sent 11/10/17. All other consumer ISP review records will be available per request following 12/31/17.
5. Attachment Names
a. ISP review #1 titled ¿Attachment 1 ¿ 2380.186(a)¿
b. ISP review #2 titled ¿Attachment 2 ¿ 2380.186 (a)¿ |
12/31/2017
| Implemented |
| Article X.1007 | Vista's Community Integration Center is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including 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 #3 was hired on 4/17/17; the FBI fingerprint clearance was dated 4/28/17. | 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. | 1. Who/What/When/How
a. Previously Vista was operating under the presumption employees could be hired on a 30-day provisional basis while waiting for FBI clearances to be received. This occurred for 2 employees that had previously worked out of state. Vista now understands these clearances must be possessed before employment is offered. Vista will not hire employees requiring FBI clearances unless in possession and free of record effective immediately (11/10/17).
2. Long Term Preventative Plan
a. Human Resource team vets all applicants and determines where FBI clearances are necessary. A check-and-balance system has been established across multiple HR members.
3. Training
a. HR has reviewed internal policies and made adjustments to ensure in compliance as indicated by regulations. Internal HR team members have all been trained on the updated policy (noted as complete 11/10/17).
4. Evidence
a. Vista¿s policy is updated to reflect FBI clearance requirements.
5. Attachment Names
a. Background Check Policy titled ¿Attachment 12 - Background Check Policy¿ |
11/10/2017
| Implemented |