| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | A written fire drill record was not kept of the date, time, the amount of time it took for evacuation, agency failed to provide October 2020 Fire Drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Regulation 6400.12C:
Importance of Regulation
o This regulation is critical for maintaining and ensuring the safety of the individual.
Regulation Violated
o A written fire drill record was not kept of the date, time, the amount of time it took for evacuation, agency failed to provide October 2020 Fire Drill.
Fix of Violation.
The October 2020 monthly fire drill was located in a different folder and immediately filed correctly.
Responsible Person
o Douglas Jones is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 4/15/21.
o Violation was resolved on 3/29/21
o Based on analysis of other individuals, there are no similar violations. |
03/29/2021
| Implemented |
| 6400.141(c)(6) | The physical exam for Individual #1 indicated most recent TB Test dated was 6/24/15, TB test are to be completed every two years. No documentation of current TB test was provided at time of inspection. | 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. | Regulation 6400. 141C.10
Importance of Regulation
o This regulation is critical for maintaining good health of the individual.
Regulation Violated
o The physical exam for Individual #1 indicated most recent TB Test dated was 6/24/15, TB test are to be completed every two years. No documentation of current TB test was provided at time of inspection. The box on the individual¿s physical form which states `individual is free of all communicable diseases¿ was not checked by the physician.
Fix of Violation
o At individual's most recent PCP visit on 5/20/21, the PCP correctly filled the form out and indicated that the TB test had been completed.
Responsible Person
o Douglas Jones is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 4/15/21
o Violation was resolved on 5/25/21
o Based on analysis of other individuals, there are no similar violations |
05/20/2021
| Implemented |
| 6400.165(f) | Individual #1did not have a current Behavior Support Plan in the file at time of inspection, individual date of admission was 2/5/21. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Importance of Regulation
o This regulation is critical for ensuring that staff persons supporting the individual are fully trained on the do¿s and don¿ts to adequately the individual.
Regulation Violated
o Individual #1did not have a current Behavior Support Plan in the file at time of inspection, individual date of admission was 2/5/21.
Fix of Violation.
o Acute Behavior Specialist worked closely with the County and other stake holder to draft a behavior plan. However, the individual did not return to Acute¿s program and the behavior plan was not finalized. Because the individual returned to the Selinsgrove center on 4/20/2021, directly from the hospital, the plan was not completed.
Responsible Person
o Victoria Tarpeh is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 4/15/21
o Violation was resolved on 4/15/21
o Based on analysis of other individuals, there are no similar violations |
04/20/2021
| Implemented |
| 6400.213(1)(i) | A dated Photograph for Individual #1 was not present in the individual records at time of inspection. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Regulation 6400. 213
Importance of Regulation
o This regulation is critical for making sure the individual¿s records are up to date and to ensure all individual can be easily identified.
Regulation Violated
o A dated Photograph for Individual #1 was not present in the individual records at time of inspection.
Fix of Violation.
o The program specialist attempted to get a recent photo of the individual but was not accessible. The individual is no longer a part of Acute and decided she wanted to leave and return to Selinsgrove center.
Responsible Person
o Summer Kollie is responsible to prevent future violations.
o Acute anticipated the resolution of this violation by 4/20/21
o Violation was resolved on 4/20/21
o Based on analysis of other individuals, there are no similar violations |
04/20/2021
| Implemented |