| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(b)(10) | The program specialist did not review, sign and date monthly documentation for Individual #3 for October 2016, November 2016 and December 2016. The program specialist did not review, sign and date monthly documentation for Individual #4, date of admission 12/21/15 for prior to 3/15/17. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes. | By 12/22/2017 for the survey sample, and all others, the Program Specialist will review, sign and date all monthly documentation currently on file. This practice will continue as specified in the regulations. For a period of 6 months, the Director of IDD Services will review a 50% sample to ensure completeness. Quarterly, thereafter, the Director of IDD Service will review a 25% sample to ensure the same. [Immediately, the Director of IDD services shall educated the program specialist(s) of the responsibilities of the position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. Documentation of all aforementioned audits shall be kept. (AS 12/8/17)] |
12/22/2017
| Implemented |
| 2380.36(c) | Direct Service Worker #2 had 12 hours of training for training year, 1/1/16 to 12/31/16. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | By 12/31/17, the end of the training year, the survey sample and all other staff, as indicated by regulations, will have at least 24 hours of training relevant to human services. This training will be maintained in a binder for review by staff ongoing. Monthly, thereafter, the Program Specialist will review the binder for progress and ensure at least 24 hours will be completed by the end of the training year (calendar). Quarterly, thereafter, the Director of IDD Services will review the binder for progress ensure at least 24 hours will be completed by the end of the training year (calendar). [Documentation of all aforementioned audits shall be kept. (AS 12/8/17)] |
12/31/2017
| Implemented |
| 2380.84 | The facility, date of opening 3/12/16, has not had a fire safety inspection by a firesafety expert. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | The facility will be inspected by a fire expert by 12/29/2017 and annually thereafter. Documentation of the date, source and results of the fire safety inspection will be reviewed by the Program Specialist for completeness and maintained at the licensed facility. [Immediately, the Director shall develop and implement a tracking system to ensure timely completion of the fire safety inspection and documentation is maintained as required. The director shall train staff responsible, immediately after the development of the tracking system. At least annually, the director shall review the process and fire inspection documentation annually to ensure timely completion with all required information. (AS 12/8/17)] |
12/29/2017
| Implemented |
| 2380.91(a) | Individual #1, date of admission 6/19/17 and Individual #2, date of admission 5/1/17 were not instructed in fire safety. Individual #3 was instructed in fire safety on 8/29/16 and then again on 10/2/17. Individual #4 was most recently instructed in fire safety on 12/21/15. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility. | As of 11/27/2017 the survey sample, and all others, have been trained on 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 facility. Documentation of this has been generated and will be maintained at the licensed facility. Ongoing, upon admission, and annually thereafter, individuals will be trained on the same information listed above. The Program Specialist will generate the documentation showing it has been completed. Quarterly review of this training will be completed by the Director of IDD Services. [Documentation of audits shall be kept. (AS 12/8/17) |
11/27/2017
| Implemented |
| 2380.91(c) | The record of the fire safety trainings held on 12/21/15, 8/29/16, and 10/2/17 did not include the content of the training. | A written record of firesafety training, including the content of the training and individuals attending, shall be kept. | The training sign in form has been updated to include a field for content of training so that future trainings are compliant. All participants were re-trained on 11/27/17. The Program Specialist will ensure that future documentation of trainings is complete. The Director of IDD Services will review the training forms quarterly to ensure compliance. [Documentation of reviews shall be kept. (AS 12/8/17)] |
11/27/2017
| Implemented |
| 2380.111(c)(3) | The physical examination for Individual #1, completed 5/5/17, did not include dates of the Tetanus and Diphtheria immunizations. The physical examination for Individual #2, completed 10/11/17, did not include dates of the Tetanus and Diphtheria immunizations. The physical examination for Individual #3, completed 7/10/17, did not include dates of the Tetanus and Diphtheria immunizations. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | A new physical form is being used to include dates of immunizations. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including immunizations. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.111(c)(4) | The physical examination for Individual #4, completed 12/2/16 did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | A new physical form is being used to include vision and hearing screenings. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including vision and hearing screenings. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.111(c)(5) | The physical examination completed on 7/10/17 for Individual #3, date of admission 8/19/16, did not include Tuberculin skin testing. This section on the physical examination form was blank. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | For Individual #3, a copy of a completed negative tuberculin skin test dated 2/27/2017 was obtained. Ongoing, a new physical form is being used to include tuberculin skin test results or x-ray as required by regulations. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including tuberculin skin test results or x-ray as required by regulations. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.111(c)(6) | The physical examination for Individual #3 completed on 7/10/17, did not address communicable disease; therefore, compliance could not be measured. | 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. | A new physical form is being used to include specific precautions that shall be taken if the individual has a serious communicable disease. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including specific precautions that shall be taken if the individual has a serious communicable disease. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.111(c)(7) | The physical examination for Individual #1, completed 5/5/17, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was blank. The physical examination for Individual #2, completed 10/11/17, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was blank. The physical examination for Individual #3, completed 7/10/17, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was blank. | 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. | A new physical form is being used to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.111(c)(8) | The physical examinations for Individuals #1, completed 5/5/17, did not include the physical limitations of the Individuals. The physical examination for Individual #2, completed 10/11/17, did not include the physical limitations of the Individuals. The physical examination for Individual #4, completed 12/2/16, did not include the physical limitations of the Individuals. | The physical examination shall include: Physical limitations of the individual. | A new physical form is being used to include the physical limitations of the Individuals. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including the physical limitations of the Individuals. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.111(c)(10) | The physical examination for Individual #1, completed 5/5/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination for Individual #2, completed 10/11/17,did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination for Individual #3, completed 7/10/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination for Individual #4, completed 12/2/16, did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A new physical form is being used to include medical information pertinent to diagnosis and treatment in case of an emergency. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including medical information pertinent to diagnosis and treatment in case of an emergency. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.111(c)(11) | The physical examination for Individual #1, completed 5/5/17, did not include special instructions for the Individual's diets. The physical examination for Individual #2, completed 10/11/17, did not include special instructions for the Individual's diets. The physical examination for Individual #4, completed 12/2/16, did not include special instructions for the Individual's diets. | The physical examination shall include: Special instructions for an individual's diet. | A new physical form is being used to include special instructions for the Individual's diets. For the survey sample and all others, by 12/22/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the new physical form to be updated by the individual¿s doctor to include any missing information, including special instructions for the Individual's diets. By 1/19/2018, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
01/19/2018
| Implemented |
| 2380.113(a) | Program Specialist #1, date of hire 8/16/16, had a physical examination completed 8/29/16. Direct Service Worker #4, date of hire 7/21/17, had a physical examinations completed 7/23/17. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | As new staff are hired it will be made clear to them that they are not able to start, attend new hire orientation, or be employed in any manor until they have completed and submitted a physical, to include a tuberculin skin test or x-rays, as required by regulations. If a new employee were to show up to new hire orientation, identified as their first day of work, without this being completed, they would be sent home, without pay and their orientation day will be rescheduled. A copy of their physical will be reviewed by the Director of IDD Services and maintained in their HR file. |
12/07/2017
| Implemented |
| 2380.113(c)(2) | Program Specialist #1, date of hire 8/16/16, had Tuberculin skin testing completed 8/19/16. Direct Service Worker #4, date of hire 8/17/17 had Tuberculin skin testing completed 8/18/17. Direct Service Worker #3, date of hire 7/21/17 had Tuberculin skin testing completed 7/23/17. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant. | As new staff are hired it will be made clear to them that they are not able to start, attend new hire orientation, or be employed in any manor until they have completed and submitted a physical, to include a tuberculin skin test or x-rays, as required by regulations. If a new employee were to show up to new hire orientation, identified as their first day of work, without this being completed, they would be sent home, without pay and their orientation day will be rescheduled. A copy of their physical will be reviewed by the Director of IDD Services and maintained in their HR file. [Prior to hire, the Director of IDD Services shall review staff persons physical examination to ensure all required information is included and completed, timely. (AS 12/8/17)] |
12/07/2017
| Implemented |
| 2380.173(1)(ii) | The record for Individual #3 did not include 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. | The record for Individual #3 was updated. By 12/29/2017, for the survey sample and all others, the Program Specialist will ensure each individual has been provided an updated copy of the Client Emergency Information Sheet to be updated and submitted to the Program Specialist. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each Client Emergency Information Sheet has been updated as needed and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. |
12/29/2017
| Implemented |
| 2380.181(e)(10) | The assessment for Individual #1, dated 7/3/17, did not include a lifetime medical history. The assessment for Individual #2, dated 5/10/17, did not include a lifetime medical history. The assessment for Individual #3, dated 10/28/17, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | For the survey sample and all others, the Program Specialist will review all assessments and update as necessary, to include lifetime medical history. By 12/29/2017, the Director of IDD Services will review the assessments for completeness. Ongoing, the Program Specialist will complete an initial assessment for individuals within 60 calendar days after admission and annually thereafter. The assessments will be sent to the team members along with a cover letter and both documents will be filed in the respective charts. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each assessment has been updated as needed and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. [Individuals #1, #2, #3s' assessments were updated to include lifetime medical history on 12/11/17. (AS 12/12/17)] |
12/29/2017
| Implemented |
| 2380.181(e)(12) | The assessment for Individual #2, completed 5/10/17 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. This section was blank. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The assessment for individual #2 was updated to include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. For the survey sample and all others, the Program Specialist will review all assessments and update as necessary, to include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. By 12/29/2017, the Director of IDD Services will review the assessments for completeness. Ongoing, the Program Specialist will complete an initial assessment for individuals within 60 calendar days after admission and annually thereafter. The assessments will be sent to the team members along with a cover letter and both documents will be filed in the respective charts. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each assessment has been updated as needed and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office.[Individuals #1, #2, #3s' assessments were updated to include recommendations for specific areas of training, vocational programming and competitive community-integrated employment on 12/11/17. (AS 12/12/17)] |
12/29/2017
| Implemented |