| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | According to the financial log, Individual #1's ending balance as of July 9, 2017 was $89.06. Individual #1 only had $84.07 in cash. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Disbursements made to or for the individual.
| 55 PA Code Chapter 6400.22(d)(2)
Miscalculation of funds
To fix the immediate problem an audit of the funds was done. It was found that the source/cause of the discrepancy was a miscalculation on the part of the staff member who did the documentation last.
To prevent future errors, the Financial Record Log was re-designed by simplifying it ¿ Attachment #21.
Calculators were purchased and placed in each individuals¿ money box to assist staff in doing their calculations.
Double-staff check system was further emphasized for all staff members.
Staff members were supervised for the first one week. Spontaneous checks by the Program Specialist have also been adopted. Weekly reviews by the Program Director is also done. The CEO provides oversight. |
08/12/2017
| Implemented |
| 6400.46(j) | According to the staff training records, Staff #2 and #3 received orientation training. The training records did not include dates of when the training was completed. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | 55 PA Code Chapter 6400.46(j)
Date of Orientation Training for Staff #s 2 & 3
As an immediate fix, Staff #2 & Staff #3 had a repeat of their Orientation Training.
Other staff persons were also reviewed to assure mastery of the materials.
Training Sign-In Sheet was previously attached as Attachment #20.
To prevent future occurrences, the Program Specialist will be re-trained on the training content and needed documentation.
All trained staff will sign off on the training attendance sheet to confirm that they were trained on the specific date.
The Human Resource Director will provide oversight to the Program Specialist for training needs. The Human Resource Director shall review all training materials and sign-in sheets.
No employee will be allowed to work the individuals until they have completed their Orientation Training. The Training syllabus is attached as Attachment #6. |
08/23/2017
| Implemented |
| 6400.62(a) | Individual #1's Individual Support Plan (ISP) indicated, "it is unknown if Individual #1 would be aware of how to use these materials." Individual #1 was not assessed by Ideal Services to be safe around poisonous materials. The following items were stored under the unlocked bathroom sink: Febreze, Scrubbing bubbles, Spic and Span, Window Cleaner, Comet Cleaner, and Right Gaurd. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 55 PA Code Chapter 6400.62(a)
All the poisonous materials were locked up in locked cabinets immediately.
To avoid future occurrence, the Program Specialist briefed and re-trained all staff on the need to lock up all poisonous materials.
The Direct Care Supervisor shall enforce this practice.
The Program Specialist shall supervise her. |
08/12/2017
| Implemented |
| 6400.72(b) | The bottom of the screen in the front door was ripped the length of the screen. | Screens, windows and doors shall be in good repair. | 55 PA Code Chapter 6400.72(b)
Screen in good repair
The screen has been repaired immediately.
The Direct Care Supervisor shall report all maintenance needs to the Program Director.
The Program Director shall ensure prompt repairs.
The CEO shall provide oversight. |
08/12/2017
| Implemented |
| 6400.76(a) | The dryer contained lint the size of a baseball. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 55 PA Code Chapter 6400.76(a)
Lint in dryer
The lint in the dryer was removed immediately.
All staff members were briefed about the danger/hazard of leaving lint in the dryer.
Direct Care Supervisor shall check on this daily or assign another staff to do it.
The Program Specialist shall supervise her. |
08/12/2017
| Implemented |
| 6400.80(b) | A drainage pipe was laying across the ground in the backyard creating a tripping hazard. A piece of drainage pipe was discarded on the ground next to the garage. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 55 PA Code Chapter 6400.80(b)
2 drainage pipes in the yard.
To fix the immediate problem, the pipes have been removed and discarded immediately.
The Program Specialist shall ensure a safe environment now and in the future.
To prevent a future occurrence:
1. The Program Specialist shall ensure that outside conditions of the home are well maintained to guarantee safety:
a. Outside walkways shall be free from ice, snow, obstructions and other hazards.
b. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.
This will be achieved according to the following procedure.
2. The daytime staff shall complete a walk-through daily, and document it on the Walk-Through Checklist form attached as Appendix #5A. Remediation shall be effected as the need arises.
3. Maintenance needs that is beyond the staff¿s ability/scope of operation to fix shall be documented on a Work Order Requisition form (attached as Attachment #5B) and submitted to the Program Specialist. In addition to this, the maintenance need will be verbally reported to the Program Specialist to expedite action.
4. The Direct Care Supervisor will walk through the home (inside and outside) once in a week, and document her findings on the Walk-Through form (Attachment #5A). The Direct Care supervisor will submit the Walk-Through form as well as the Work Requisition Order (if needed) form to the Program Specialist weekly.
5. The Program Specialist shall walk through the home (inside and outside) monthly, and document her findings on the Walk-Through form (Attachment #5A).
6. The CEO will provide oversight for this aspect. He will review all paperwork pertinent to this on a quarterly basis. |
08/23/2017
| Implemented |
| 6400.103 | The written evacuation plan did not include the location of the emergency shelter. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| 55 PA Code Chapter 6400.103
Location of Emergency Shelter in the Written Evacuation Plan
Emergency Shelters:
As an immediate fix, an emergency shelter has been designated. The emergency shelter in the event of an emergency is a hotel. The designated hotel of choice is Hampton Inn, 4230 Union Deposit Road, Harrisburg, PA 17111.
To prevent future violations, the agency¿s written Policy and Procedures on Emergency Evacuation Procedures has been amended. Also included in the Policy are Staff and Individuals¿ responsibilities and means of transportation.
Designated Contact for Relocation:
The Program Specialist
The CEO shall provide supervision for the Program Specialist.
All employees will receive training on Emergency Evacuation Procedures at Orientation.
The Program Specialist shall review this policy with the Direct Care Staff on a quarterly basis to ensure that every employee is familiar with the Evacuation Process.
All employees will sign off on an attendance sheet to document that they went through the quarterly review of the policy.
The CEO shall review all the records collated by the Program Specialist on a quarterly basis.
The Policy is attached as Attachment #4. |
08/23/2017
| Implemented |
| 6400.112(c) | There was no record of a fire drill in October of 2016. | 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. | 55 PA Code Chapter 6400.112(c)
Record of October 2016 Fire Drill
To fix the immediate problem, a record of the Fire Drill for October 17, 2016 was located. There was actually an October 2016 Fire Drill. However, the record was not located on the day of Inspection. The record has been sent previously as Attachment #18.
A summary of the record is as follows:
¿ The Date of the of the Fire Drill: October 17, 2016
¿ Time of Drill: 5: 00 pm
¿ Amount of Time it took for Evacuation: 1 minute, 15 seconds
¿ Exit Route: Front Door
¿ Evacuation was completed successfully (no problems).
¿ All smoke detectors were operative.
The non-compliance/violation was a deficiency in record keeping (the records could not be located on the Inspection day.
To prevent future occurrences, the system of filing in the agency will be revamped:
1. The Program Specialist shall ensure a system of thorough filing.
2. The Program Specialist will ascertain that all Fire Drill records are intact as she adds on the monthly records.
3. A quarterly audit will be done by the CEO.
4. All records will be reviewed and collated annually by the CEO.
The agency¿s Policy and Procedures on Fire Safety is attached as Attachment#3. |
08/23/2017
| Implemented |
| 6400.141(a) | Individual #1 had a physical exam completed on 2/12/17 and not again until 4/20/17. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 55 PA Code Chapter 6400.141(a)
Frequency of Individual #1¿s Physical exam.
Individual #1 had a physical completed in February 2016 in order to complete his MA 51. This was done by Erica Musser, Physician¿s Assistant at Hershey Medical Center. Individual #1 had another physical examination completed in April 2016 in order to complete Ideal Services Group¿s comprehensive physical examination form. This was completed by Dr. Laurie Nelson of Hershey Medical Center. This was actually only two months apart. |
08/12/2017
| Implemented |
| 6400.141(c)(1) | Individual #2's 11/9/16 physical exam did not include a medical history. | The physical examination shall include: A review of previous medical history. | 55 PA Code Chapter 6400.141(c)(1)
Individual #2¿s Physical Exam of 11/9/16 ¿ A review of previous medical history
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s previous medical history from his Primary Care Doctor. A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this.
The document shall be obtained and placed on file as soon as it is received.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in. |
08/12/2017
| Implemented |
| 6400.141(c)(3) | Individual #2's 11/9/16 physical exam did not include a tetanus and diphtheria immunization or any other immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | 55 PA Code Chapter 6400.141(c)(3)
Individual #2¿s Physical Exam of 11/9/16 ¿ Tetanus & Diphtheria Immunization
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s record of Tetanus & Diphtheria immunization record from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In case there is no record of his immunizations, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.141(c)(4) | Individual #2's 11/9/16 physical exam did not include a section for a vision or hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 55 PA Code Chapter 6400.141(c)(4)
Individual #2¿s Physical Exam of 11/9/16 ¿ Vision & Hearing Screening
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s record of Vision and Hearing Screening from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
Furthermore, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.141(c)(6) | Individual #2's 11/9/16 physical exam did not include tuberculin skin testing. Individual #1 was admitted to the program on 10/17/16. Tuberculin skin testing was completed on 12/19/16. | 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. | 55 PA Code Chapter 6400.141(c)(6)
Tuberculin skin testing for both individuals
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s record of Tuberculin Skin Testing report from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In case there is no record of his TB status, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this.
For Individual #1, the tuberculin testing shall be repeated by 12/19/18 to ensure that we stay in compliance.
The Program Specialist shall keep track of all individuals¿ future appointments.
The CEO shall provide oversight. |
08/12/2017
| Implemented |
| 6400.141(c)(10) | Individual #2's 11/9/16 physical exam did not include his/her communicable disease status. | 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. | 55 PA Code Chapter 6400.141(c)(10)
Communicable disease status
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s Communicable Disease Status from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In addition, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.141(c)(11) | Individual #2's 11/9/16 physical exam did not include health maintenance needs, medication regimen, or the need for blood work. | 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. | 55 PA Code Chapter 6400.141(c)(11)
Health maintenance needs, medications regimen, or need for blood work.
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s record of Health Maintenance Needs, Medications Regimen or Need for Blood Work from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In addition, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.141(c)(12) | Individual #2's 11/9/16 physical exam did not include physical limits. | The physical examination shall include: Physical limitations of the individual. | 55 PA Code Chapter 6400.141(c)(12)
Physical limitations of the individual
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s Communicable Disease Status from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In addition, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.141(c)(13) | Individual #2's 11/9/16 physical exam did not include allergies. | The physical examination shall include: Allergies or contraindicated medications. | 55 PA Code Chapter 6400.141(c)(13)
Allergies
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s record of known allergies from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In addition, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.141(c)(14) | Individual #2's 11/9/16 physical exam did not include information pertinent to diagnois and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 55 PA Code Chapter 6400.141(c)14)
Information pertinent to diagnosis and treatment in case of emergency.
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s Information pertinent to diagnosis and treatment in case of an emergency from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In addition, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.141(c)(15) | Individual #2's 11/9/16 physical exam did not include diet instructions. | The physical examination shall include:Special instructions for the individual's diet. | 55 PA Code Chapter 6400.141(c)(15)
Diet Instructions
An immediate fix to the problem is that Ideal Services Group has requested Individual #2¿s Diet Instructions from his Primary Care Physician (PCP). A copy of the request letter, as well as the form, is attached ¿ Attachment #17.
The document shall be obtained and placed on file as soon as it is received.
In addition, an appointment has been scheduled for him to see his PCP. The visit is scheduled for August 23, 2017. That is the earliest appointment offered him. All needed documentation will be taken care of on or before that appointment.
To prevent future occurrences, all such documentations shall be obtained before an individual can move in.
The Program Specialist shall be responsible for completing the pre-admission documentation.
The CEO shall provide oversight on this. |
08/12/2017
| Implemented |
| 6400.151(a) | Staff #3 was hired on 1/10/17. The physical exam was completed on 7/1/17. Staff #2 was hired on 7/1/16. The physical exam was completed on 7/15/16. | 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. | 55 PA Code Chapter 6400.151(a)
Staff #2 was hired on 7/1/16 and had her physical on 7/15/16. Staff #2 did not come into contact with individuals until October 17, 2016, since that was the first day our first individual came into the home.
Staff #3¿s physical examination documentation was actually late.
Going forward, the agency shall implement a policy of not having staff work without completing all needed documentation, including their physical examination.
The Director of Administration/Human Resources shall enforce this.
The CEO shall provide oversight. |
08/12/2017
| Implemented |
| 6400.151(b) | Staff #3's physical exam was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | 55 PA Code Chapter 6400.151(b)
The date on Staff #3¿s physical examination has been updated immediately - Attachment #16.
The Director of Administration/Human Resources shall ensure strict scrutiny such that no omissions will occur in the future. The CEO shall review documents as a second level check to avoid errors. |
08/12/2017
| Implemented |
| 6400.151(c)(2) | Staff #3 was hired on 1/10/17. Tuberculin skin testing was completed on 7/4/17. Staff #2 was hired on 7/1/16. Tuberculin skin testing was completed on 7/15/16. | 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. | 55 PA Code Chapter 6400.151(c)(2)
Tuberculin Test on Staff 2 & 3
Staff #2 was hired on 7/1/16 and had her physical on 7/15/16. Staff #2 did not come into contact with individuals until October 17, 2016, since that was the first day our first individual came into the home.
Staff #3¿s physical examination documentation was actually late.
Going forward, the agency shall implement a policy of not having staff work without completing all needed documentation, including their physical examination.
The Director of Administration/Human Resources shall enforce this.
The CEO shall provide oversight. |
08/12/2017
| Implemented |
| 6400.161(b) | Individual #1 was prescribed SF 5000 Plus 1.1% Dental Cream. The dental cream was stored in an unlocked drawer in the bathroom. Ideal Services did not assess Individual #1's ability to safely use toxic materials. | Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. | 55 PA Code Chapter 6400.161(b)
Individual #1¿s prescription Dental Cream was locked up in the locked medications cabinet immediately.
Since it is not documented that Individual #1 can safely use and avoid toxic materials, his prescription toothpaste shall be locked up.
All Support staff are responsible for ensuring that the prescription dental cream is not left unsecured. A training and briefing session on this was held July 12 to reinforce this practice Sign-in Sheet attached ¿ Attachment #15.)
To prevent future occurrence, this aspect will be covered in Medications Administration Training and re-trainings. The Medications Administration Trainer will be responsible for providing the trainings.
The Program Specialist as well as the Medications Administration Trainer will be responsible for enforcing this practice of locking up the dental cream up. |
08/12/2017
| Implemented |
| 6400.163(c) | Individual #1 was prescribed .5mg of Lorezepam. Psychiatric medication reviews were not completed. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 55 PA Code Chapter 6400.163(c)
A visit with Individual #1¿s prescribing doctor for Lorazepam was scheduled immediately. Residential Staff accompanied Individual #1 to his doctor¿s visit on July 19. (Outpatient Visit Summary attached as Attachment #12.) The doctor, Dr. Laurie Nelson reviewed the reason for the prescribing the medication, the need to continue using it, and the necessary dosage.
A quarterly medication review will be scheduled henceforth. The next visit is scheduled for October 25, 2017 (Appointment print-out attached as Attachment #13.)
To prevent future occurrences, a Doctors¿ Visit Log will be kept of all visits.
The CEO shall review the appointment logs as well as the doctors¿ visits logs on a monthly basis.
The agency¿s policy on prescription medication is attached ¿ Attachment #14. |
08/12/2017
| Implemented |
| 6400.168(a) | Staff #1, #3, #4, and #5 were administering medications to Individual #1 and #2. There were no staff members working in the home that have completed and passed the Department's Medication Administration Training Course. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | 55 PA Code Chapter 6400.168(a)
Medications Administration
As an Immediate Fix:
Ideal Services Group contracted the services of a Registered Nurse to administer medications when trained staff was not available.
In addition, a new employee who had completed and passed the Departments¿ Medications Administration course has been hired by the agency. Details of the content of her training is attached as Attachment #2.
Staff #5 is currently certified as a Medications Administration Trainer for Pennsylvania. (Certificate was previously sent in as Attachment #11.)
To Prevent Future Occurrences:
1. Only staff persons who have completed and passed the Department¿s Medications Administration Course will permitted to administer oral, topical and eye and ear drop prescription medications.
2. The Human Resource Director shall confirm employees¿ eligibility to administer medications before they will be allowed to administer medications. Both the Medications Administration Trainer, the Program Specialist, and the Human Resource Director will confirm and sign off on the employees¿ certificate of Medications Administration competence.
3. The agency¿s Medications Administration Trainer will continue to train and re-train all residential employees (Chapter 6400.168(c).
4. Other competent employee will be offered the Trainers¿ and Practicum Observers¿ trainings.
5. New employees will not be allowed to administer medications until they have completed and passed the Department¿s Medications Administration Course.
6. Newly-trained employees shall administer medications under the supervision of the Medications Administration Trainer or a Practicum observer until they can demonstrate competence and pass the Department¿s prescribed training.
7. The agency¿s Practicum observer and Trainer shall provide on-going monitoring on a weekly/monthly basis to eliminate errors.
8. Training and re-training of staff persons and practicum observers (on Medications Administration) will be an on-going process in the agency.
9. Documentation of dates and locations of medications administration training for employees shall be meticulously kept.
10. The agency¿s Practicum Observers will give weekly reports to the Medications Administration Trainer.
11. The Medications Administration Trainer will provide supervision for all Practicum Observers.
12. A monthly audit of all medications-related paperwork will be done by the Medications Administration Trainer.
The agency¿s Policy and Procedures on Medications is attached as Attachment #2. Please take note of Sub-heading #8 ¿ Medications Administration Training. |
08/23/2017
| Implemented |
| 6400.181(a) | Individual #1 was admitted to the program on 10/17/16. Individual #2 was admitted to the program on 4/6/17. The program specialist did not complete initial assessments for Individual #1 or Individual #2. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Initial Assessments for Individuals #1 & #2 have been completed by the Program Specialist attached as Attachments #9 & #10.
The Program Specialist is responsible for completing these assessments.
Going forward, she shall complete them within 60 days of admission, per regulation.
The CEO shall offer oversight on this. |
08/12/2017
| Implemented |
| 6400.183(5) | Individual #1 is prescribed medication to treat anxiety. A social, emotional, enviornmental needs plan was not included with the Individual Support 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. | 55 PA Code Chapter 6400.183(5)
The protocol to address Individual #1¿s Social, Emotional, and Environmental Needs (S E E N Plan) has been developed by the Program Specialist immediately.
All residential staff members are immediately trained on the SEEN Plan. A copy of the plan shall be made accessible to the staff at all times (in the locked cabinets for documentation).
The plan shall be reviewed at monthly meetings. Feedbacks shall be received from staff, and reviews shall be made as needed.
To prevent future violations, Ideal Services Group¿s CEO shall oversee the Program Specialist to ensure a timely development and implementation of needed SEEN Plans.
A copy of the Seen Plan is Attachment #8. |
08/12/2017
| Implemented |
| 6400.183(7)(i) | Individual #2's Individual Support Plan did not include his/her potential to advance in residential independence. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Residential independence. | 55 PA Code Chapter 6400.183(7)(i)
Potential to advance in Residential Independence ¿ Indiv. 2
moved to his residential home in April 2017. Prior to that he lived in dorm care. On his intake, it was reported that for many years Individual #2 depended on his brother to do most things for him. As noted in his initial assessment Individual #2 needs assistance with his daily living skills to include personal hygiene, washing up and brushing teeth. Toileting, and reminders to use the bathroom and wash hands several times every night. Staff work with Individual #2 to provide all assistance needed. Individual #2 is incontinent, and uses depends at bedtime. An awake overnight is required to monitor and prompt Individual #2 to use the bathroom. He needs supervision 24 hours a day, 7 days a week. |
08/12/2017
| Implemented |
| 6400.183(7)(ii) | Individual #2's Individual Support Plan did not include his/her potential to advance in community involvement. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Community involvement. | 55 PA Code Chapter 6400.183(7)(ii)
Potential to advance in community involvement ¿ Indiv. 2
Residential support staff continue to assist Individual #1 to attend church on Sundays, attending Sunshiners program on Thursdays, going out to eat at local restaurants once or twice a week, and going to the Friendship Community center on Saturdays. Residential support staff provide Individual #1 with transportation to Patch-n-Match 5 days a week. Support staff also provide assistance with management of personal funds, as well as shopping for Individual #1's personal supplies. |
08/12/2017
| Implemented |
| 6400.183(7)(iii) | Individual #2's Individual Support Plan did not include his/her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | 55 PA Code Chapter 6400.183(7)(iii)
Potential to Advance in Vocational Programming ¿ Individual #2
To Fix the Immediate Problem:
Individual #2¿s Residential Support team (the Program Specialist as the lead) will work with him to explore his interests and preferences in vocational programming. The residential team will collaborate with other plan team members to identify Job Supportive Service agencies that can assist him with vocational skills assessment and training. Efforts will be geared towards honing his job-related skills and competence towards his preferred vocation.
The Program Specialist, as the plan lead, shall make recommendations regarding the revised assessment to Individual #2¿s plan team members at a team meeting scheduled for August 24, 2017. The above revised assessment of the service outcome will be recommended.
If the team is in agreement with the recommendation, the revised service outcome shall be implemented by the start date that will be documented in the ISP.
To prevent future occurrences:
1. The CEO will re-train the Program Specialist on the scope and frequency of ISP reviews and revisions for individuals.
2. Ideal Services Group¿s CEO shall review the Program Specialist¿s monthly review and assessments of the ISP.
3. The CEO shall review and confirm the changes documented by the Program Specialist on a monthly basis.
4. Quarterly internal audits will be put in place to ensure that compliance is achieved with the process of ISP Reviews and Revisions for individuals.
5. Annual updates will be completed with the individual and the plan team.
Ideal Services Group¿s Policies and Procedures on ISP Implementation, Review, and Revision shall be amended. This is attached as Attachment #1.
Ideal Services Group¿s Policy on ISP Implementation, Review and Revision is attached as Attachment #1. |
08/23/2017
| Implemented |
| 6400.183(7)(iv) | Individual #2's Individual Support Plan did not include his/her potential to advance in competitive employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| 55 PA Code Chapter 6400.183(7)(iv)
Potential to Advance in Competitive Employment ¿ Individual #2
To Fix the Immediate Problem:
Once a Supportive Employment agency has been identified, Individual #2 will be encouraged to work with them to advance into competitive employment with time. This will be based on his interests, preferences, and ability. Team members will continue to work with collateral agencies in order to support him for optimal advancement in this area.
The Program Specialist, as the plan lead, shall make recommendations regarding the revised assessment to Individual #2¿s plan team members at a team meeting scheduled for August 24, 2017. The above revised assessment of the service outcome will be recommended.
If the team is in agreement with the recommendation, the revised service outcome shall be implemented by the start date that will be documented in the ISP.
To Prevent Future Occurrences:
1. The CEO will re-train the Program Specialist on the scope and frequency of ISP reviews and revisions for individuals.
2. Ideal Services Group¿s CEO shall review the Program Specialist¿s monthly review and assessments of the ISP.
3. The CEO shall review and confirm the changes documented by the Program Specialist on a monthly basis.
4. Quarterly internal audits will be put in place to ensure that compliance is achieved with the process of ISP Reviews and Revisions for individuals.
5. Annual updates will be completed with the individual and the plan team.
Ideal Services Group¿s Policies and Procedures on ISP Implementation, Review, and Revision shall be amended. This is attached as Attachment #1.
Ideal Services Group¿s Policy on ISP Implementation, Review and Revision is attached as Attachment #1. |
08/23/2017
| Implemented |
| 6400.186(a) | Individual #1 was admitted to the program on 10/17/16. Individual #2 was admitted to the program on 4/6/17. The program specialist did not complete Individual Support Plan Reviews for Individual #1 or Individual #2. | 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. | 55 PA Code Chapter 6400.186(a)
¿The Program Specialist shall complete an ISP review of services and ¿ if the individual¿s needs change¿.¿
For Individual #1, his needs as it would impact the services he receives have not changed since he moved into his new home on October 17, 2016. Since his needs have remained the same as of this time, the need has not arisen for an ISP review of services and expected outcomes in his ISP. As changes become evident in the future, needed review of services will be made.
1. At this point in time, no plan is needed, as there is no problem.
a. The Program Specialist will be responsible for Individual #1¿s ISP review of services and expected outcomes in the future.
b. Changes that will impact Individual #1¿s services and expected outcomes in such a way as it would enhance his service and outcomes will be reviewed and documented, if his needs change.
c. When and how this review will be done is documented in Ideal Services¿ Policy and Procedures, attached as Attachment #4. relating to ISP Review and Revision.
Individual¿s needs are reviewed at the monthly Residential Staff Meetings, and changes are noted each month, if there are any changes.
A quarterly summary of changes that are noted regarding Individual¿s services and expected outcomes in the ISP will be noted and documented by the Program Specialist (with other Residential staff members¿ input) every three months to assess the need for changes.
If it is determined that changes are needed, the Program Specialist shall make a recommendation regarding:
i. The deletion of an outcome or service which is no longer appropriate or has been completed.
ii. The addition of an outcome or service to support the achievement of a needed outcome;
iii. The modification of an outcome or service to support the achievement of an outcome or service in which progress has been made.
d. When a recommendation will be made to revise a service or outcome in the ISP, the Program Specialist shall complete a revised assessment, sign and date the ISP review signature sheet; and forward the documentation to Individual¿s Supports Coordinator and plan team members within 30 calendar days after the ISP review meeting.
e. In the event that a recommendation for a revision is made, the Program Specialist, as the plan lead, shall send an invitation for an ISP revision meeting to the plan team members within 30 calendar days after the ISP review meeting.
f. A revised service or outcome in the ISP shall be implemented by the start date in the ISP as written.
g. A quarterly internal audit will be conducted to ensure that all paperwork is completed as and when due.
h. The CEO shall provide oversight in ensuring compliance with this section of the Policy.
¿The Program Specialist shall complete an ISP review of services and ¿ if the individual¿s needs change¿.¿
For Individual #2, his needs as it would impact the services he receives have not changed since he moved into his new home on April 6, 2017. Since his needs have remained the same as of this time, the need has not arisen for an ISP review of services and expected outcomes in his ISP. As changes become evident in the future, needed review of services will be made.
2. At this point in time, no plan is needed, as there is no problem.
a. The Program Specialist will be responsible for Individual #2¿s ISP review of services and expected outcomes in the future.
b. Changes that will impact Individual #2¿s services and expected outcomes in such a way as it would enhance his service and outcomes will be reviewed and documented, if his needs change.
c. When and how this review will be done is documented in Ideal Services¿ Policy and Procedures, attached as Attachment #4. relating to ISP Review and Revision. |
08/12/2017
| Implemented |
| 6400.186(e) | The program specialist did not notify Individual #1 or Individual #2's plan team members of the option to decline the Individual Support Plan review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | 55 PA Code Chapter 6400.186(e)
The immediate plan to fix the problem:
The Program Specialist has obtained the ISP review signature sheets for both Individual #1 (Attachment #5) and Individual #2 (Attachment #6)
a. The Program Specialist is responsible for correcting the problem. The CEO shall supervise her.
b. Henceforth, Ideal Services Group¿s Program Specialist shall complete a quarterly (or more frequently if needed) ISP review with the plan team members, giving them the option to agree to or decline the review documentation.
c. An invitation to an ISP Review Meeting will be sent to all plan team members ahead of meeting time. A sample of the invitation and a copy of the signature sheet is attached as Attachment #7. |
08/12/2017
| Implemented |
| 6400.213(8)(ii) | Individual #1's record did not include a copy of the ISP annual update signature sheet. | Each individual's record must include the following information: A copy of the signature sheets for the annual update meeting. | 55 PA Code Chapter 6400.213(8)
1. A copy of Individual #1's ISP annual update signature sheet was obtained from Kelly Jurina, Supports Coordinator. The meeting was held on August 17, 2016.
a. The Program Specialist is responsible for correcting the problem.
b. The document will be placed in the individual's record.
c. The next annual update is scheduled for August 23, 2017. An invitation was also obtained for the meeting. The Program Specialist shall ensure that all meetings are attended, and documentation is placed on file henceforth.
All supporting documents are attached by e-mail as Attachment #2. |
08/12/2017
| Implemented |
| 6400.213(9) | Individual #1's record did not include a copy of the current Individual Support Plan. | Each individual's record must include the following information: A copy of the current ISP. | 55 PA Code Chapter 6400.213(9)
A copy of Individual #1¿s ISP has been printed from HCSIS and included in his record.
Page 1 of the ISP, showing the ¿Fiscal Year Begin Date¿ and ¿Plan Last Updated Date¿ is attached as Attachment #3.
The Program Specialist is responsible for ensuring that this record is kept up to date.
The CEO shall provide oversight for the Program Specialist.
The ISP will be printed as often as it is reviewed.
A quarterly internal audit will be conducted by the Program Specialist and the CEO to ensure that compliance with this regulation is not omitted. |
08/12/2017
| Implemented |
| 6400.216(a) | Individual bowel movement charting, progress notes, and goal information were stored on an unlocked shelf in the dining room. | An individual's records shall be kept locked when unattended. | 55 PA Code Chapter 6400.216(a)
1. All the individuals' records (Bowel Movement Charts, Progress Notes, and Goal Information) were immediately relocated into locked cabinets.
Staff members were briefed on the requirement to keep all records locked, and of the consequences for violation.
a. The Program Specialist will be responsible for enforcing the regulation.
b. She will ensure that all individuals¿ records are kept locked.
c. Correction is effected immediately; and going forward, compliance will be enforced at all times.
2. To prevent future occurrence, staff persons shall comply with the regulation to keep all individuals' records locked when unattended.
a. Violations of this regulation by any staff person will be attract consequences up to and including termination.
3. All staff in the home are re-trained by the Training Director and Program Specialist on the Confidentiality Policy (Attachment #1). Their responsibility to maintain this aspect of confidentiality is emphasized.
a. The policy to keep all records locked is included in the confidentiality policy of the agency ¿ Item #8 (a copy of the document is attached by e-mail as Attachment #1).
b. This regulation will be emphasized during initial orientation training for staff.
c. Re-trainings will be done periodically to remind staff of the regulation, among others.
d. The Program Specialist shall conduct spot checks from time to time, to ensure compliance.
e. The CEO shall provide oversight for the Program Specialist. |
08/12/2017
| Implemented |
| Article X.1007 | Ideal Services Group 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 #1 was hired on 1/16/17; the criminal history check was requested on 1/21/17. | 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. | 55 PA Code Chapter Article X.1007
Criminal History Check for Staff #1
To prevent future violations, prospective employees¿ Criminal History Checks will be obtained by Ideal Services Group within 5 working days after the person¿s date of hire.
For employees who reside outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person¿s date of hire.
The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
The Human Resources Director shall be responsible for obtaining all these record checks in a timely manner.
The CEO shall provide oversight on this.
Ideal Services Group¿s Policy on Criminal History Checks is attached as Attachment #7. |
08/23/2017
| Implemented |