| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | An application for a Pennsylvania criminal history record check for Direct Service Worker #1, date of hire 7/8/15, was not submitted to the State Police until 9/24/15. | 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.
| The CEO has revised the new hire checklist to include the information the Nixon Law and the steps required to hire an individual that has a prior criminal record. Hiring manager are required to take the online training to become knowledgeable about the law. These step are closely monitored by the CEO during the entire hiring process. All paperwork is required to be collected by the hiring manager and forwarded to the CEO for final review. Once all the pertinent documents are collected and reviewed by the CEO, only then can an employment offer be made. |
01/02/2016
| Implemented |
| 6400.31(b) | The statement acknowledging receipt of the individual rights was not signed or dated by Individual #1, date of admission 7/6/15. In addition, the "rights" form did not state the full rights per regulations 33(b) participating in research projects, 33(c) managing personal financial affairs, 33(d) participating in program planning that affects the individual and 33(e)privacy in bedrooms, bathrooms and during personal care. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The policy is that all new admission must sign and date all forms included in the admissions packet on the day of admission. The individual rights have been signed by the participant. [Individual #1 was discharged on 3/8/16. Individual #1 signed a revised rights form which included the missing rights which was submitted to the department of 3/16/16. The program specialist will be responsible for having the individuals sign the "rights" both upon admission and annually. PS will document on the new admission checklist. Annual documentation including "rights" is tracked on google calendar by the Program specialist. CEO will review new admission checklists and tracking calendar and compare to individual records to ensure timely completions of receipt of rights. (AS 3/8/16) |
01/02/2016
| Implemented |
| 6400.33(f) | The refrigerator is locked with a plastic coated braided wire and padlock; the kitchen cupboards are locked with locks and keys at all times. Licensing Representative was informed by the CEO that these locks are in place at all times and observed during the inspection of the home. | An individual has the right to receive, purchase, have and use personal property. | The CEO and Program Specialist will schedule a team meeting with the service coordinator, supervisor and county ODP to discuss a plan of action to address the restrictive procedure that has been denied the PA ODP. In the interim, the plan will be to continue to monitor the individual for inappropriate food consumption and behavioral intervention.[Individual #1 was discharged from the home on 3/8/16. Direct Care staff removed locks on the refrigerator and kitchen cabinets were removed on 3/9/16 and will remain unlocked so that individuals living in the home have the right to receive, purchase, have and use personal property including food items. At least weekly, program specialist will complete home visit to ensure refrigerator and kitchen cupboards are not locked and individuals have the right to receive, purchase, have and use personal property is maintained. (AS 3/31/16)] |
01/02/2016
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A procedure is in place that required the site supervisor and Program Specialist to do a walk through prior and after admission to assure that all necessary regulatory items are in place. The thermometer has been purchased and place in the first aid kit. [The first aid kit check will be added to the monthly checklist and the site supervisor will check to ensure a required items are in the first aid kit at least monthly. The Program specialist will review the monthly checklist at least quarterly to ensure completion and accuracy. Documentation of the checks shall be kept. (AS 3/8/16)] |
01/02/2016
| Implemented |
| 6400.113(a) | Individual #1, date of admission 7/6/15, was not instructed in the individual's primary language or mode of communication, upon initial admission 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 and smoking safety procedures if individuals smoke at the home. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | The fire and safety training has been included in the admissions process and will occur on day one of admission. We have included this training in our annual fire and safety calendar training. The participant has received fire and safety training. [Individual #1 received fire safety training. Individual #1 was discharged from the home on 3/8/16. Immediately, CEO will develop and implement and train the program specialist on a tracking system/checklist for initial and annual trainings to include fire safety training for individuals. The program specialist will be responsible for initial fire safety training will ensure completion upon admission will document on the new admission checklist. Annual fire safety training will be tracked by the Program specialist. CEO will review new admission checklists and annual tracking system at least quarterly to ensure timely completion of initial and annual trainings. (AS 3/31/16)] |
01/02/2016
| Implemented |
| 6400.141(c)(6) | Individual #1's physical examination completed on 9/18/14 did not include a Tuberculin skin testing by Mantoux method with negative results. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical on file prior to the first day of work. The Program Specialist and CEO will review the new hire file to assure that the physical form is on file. [Individual #1 had a physical examination to Tuberculin skin testing with negative results was completed on 10/2/15. Upon completion the Program Specialist and Director of Operations will review all new and annual individuals' physical examinations to ensure all required information is present including Tuberculin skin testing and obtain any missing information. At least quarterly for 1 year CEO will review all current individual physical examinations to ensure all required information is present including Tuberculin skin testing and obtain any missing information. Documentation of reviews shall be kept. (AS 3/31/16)] |
01/02/2016
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination completed on 9/18/14 did not include specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | 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. | The CEO has revised the employee physical form to include specific precautions in the even communicable disease is present and to prevent the spread to other. The CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical on file prior to the first day of work. The Program Specialist and CEO will review the new hire file to assure that the physical form is on file. [Individual #1 had a physical examination stating individual was free of communicable disease on 10/2/15. Upon completion the Program Specialist and Director of Operations will review all new and annual individuals' physical examinations to ensure all required information is present including communicable disease and specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. At least quarterly for 1 year CEO will review all current individual physical examinations to ensure all required information is present including communicable disease and specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals and obtain any missing information. Documentation of reviews shall be kept. (AS 3/31/16)] |
01/02/2016
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed on 9/18/14 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 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. | The CEO has revised the employee physical form to include health maintenance needs, medication regimen and blood work recommendations. The CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical on file prior to the first day of work. The Program Specialist and CEO will review the new hire file to assure that the physical form is on file.[Individual #1 had a physical examination to An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals was completed on 10/2/15. Upon completion the Program Specialist and Director of Operations will review all new and annual individuals' physical examinations to ensure all required information is present including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals and obtain any missing information. At least quarterly for 1 year CEO will review all current individual physical examinations to ensure all required information is present including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals and obtain any missing information. Documentation of reviews shall be kept. (AS 3/31/16)]
|
01/02/2016
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination completed on 9/18/14 did not include physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | The CEO has revised the employee physical form to include physical limitations. The CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical on file prior to the first day of work. The Program Specialist and CEO will review the new hire file to assure that the physical form is on file.[Individual #1 had a physical examination to physical limitations was completed on 10/2/15. Upon completion the Program Specialist and Director of Operations will review all new and annual individuals' physical examinations to ensure all required information is present including an physical limitations and obtain any missing information. At least quarterly for 1 year CEO will review all current individual physical examinations to ensure all required information is present including an assessment of the physical limitations and obtain any missing information. Documentation of reviews shall be kept. (AS 3/31/16)] |
01/02/2016
| Implemented |
| 6400.151(a) | Direct Service Worker #1, date of hire 7/8/15, had a physical examination completed on 7/29/15. | 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. | The CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical on file prior to the first day of work. The Program Specialist and CEO will review the new hire file to assure that the physical form is on file.[Documentation of the reviews shall be kept to ensure staff physicals are completed timely. (AS 3/8/16)] |
01/02/2016
| Implemented |
| 6400.181(e)(1) | Individual #1's initial assessment, completed on 7/6/15, did not include functional strengths, needs and preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including functional strengths, needs and preferences of the individual. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including functional strengths, needs and preferences of the individual. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(2) | Individual #1's initial assessment, completed on 7/6/15, did not include the likes, dislikes and interest of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals¿ assessments ensuring all required information is present including the likes, dislikes and interest of the individual. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the likes, dislikes and interest of the individual. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's initial assessment, completed on 7/6/15, did not include 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. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including the individual's current level of performance and progress in the following areas: Acquisition of functional skills. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the individual's current level of performance and progress in the following areas: Acquisition of functional skills. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's initial assessment, completed on 7/6/15, did not include the Individual's current level of performance and progress in communication. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Communication. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including the individual's current level of performance and progress in the following areas: Communication. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the individual's current level of performance and progress in the following areas: Communication. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's initial assessment, completed on 7/6/15, did not include the Individual's current level of performance and progress in personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including the individual's current level of performance and progress in personal adjustment. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the individual's current level of performance and progress in personal adjustment. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(4) | Individual #1's initial assessment, completed on 7/6/15, did not include the Individual's need for supervision. | The assessment must include the following information: The individual's need for supervision.
| The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals¿ assessments ensuring all required information is present including the individual's need for supervision. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the individual's need for supervision. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(9) | Individual #1's initial assessment, completed on 7/6/15, did not include documentation of the Individual's functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including documentation of the individual's disability, including functional and medical limitations. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including documentation of the individual's disability, including functional and medical limitations. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's initial assessment, completed on 7/6/15, did not include the individual's progress over the last 365 calendar days and current level in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including the individual's progress over the last 365 calendar days and current level in health. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the individual's progress over the last 365 calendar days and current level in health. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's initial assessment, completed on 7/6/15, did not include the individual's progress over the last 365 calendar days and current level in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including the individual's progress over the last 365 calendar days and current level in motor and communication skills. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the individual's progress over the last 365 calendar days and current level in motor and communication skills. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's initial assessment, completed on 7/6/15, did not include the individual's progress over the last 365 calendar days and current level in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The CEO has devised an admission checklist with deadline dates that will help guide the Program Specialist in completing all the necessary documentation prior to admission. The checklist will be reviewed by both the Program Specialist and the CEO. The CEO will review the documentation within 2 days and make the final approval that all documentation is completed.[Individual #1 was discharged on 3/8/16. Within 30 days of receipt of the plan of correction, CEO and designated staff will develop and implement an assessment document that addresses all required information based on 6400.181e. Program specialist will complete all individuals' assessments ensuring all required information is present including the individual's progress over the last 365 calendar days and current level in personal adjustment. For 1 year, immediately after completion, CEO or Director of Operations will review all completed assessments to ensure all required information is present including the individual's progress over the last 365 calendar days and current level in personal adjustment. Documentation of reviews shall be kept. (AS 3/31/16] |
01/02/2016
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include a current, dated photograph. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | An admission check list has been developed to assure that all regulatory items are met at the time of admission. The participants picture has been taken a placed in his chart. [Individual #1's photo was dated based on the date in the computer that the photo was taken (10/8/15) and submitted to the department on 3/16/16. Individual #1 was discharged on 3/8/16. Program specialist will be responsible for ensuring a current, dated photo is in the each individual's record and will document on the admission checklist. CEO will train the Program specialist as to this responsibility. PS will document on the admission checklist and CEO will review the checklists to ensure all required information is present in each individuals' files including a current, dated photograph. (AS 3/31/16/)] |
11/09/2015
| Implemented |