| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(b)(2) | Staff 1 is the program specialist since program open date of 11/7/17 and she was not trained on all of her program specialist duties. The program specialist job responsibilities that were missing from her training were:
1. participating in the development of the ISP, including annual updates and revisions of the isp,
2. attending isp meetings, fulfill the role of plan lead as applicable,
3. reviewing the isp, annual updates and revisions for accuracy,
4. reporting content discrepancy to the SC or plan lead as applicable, and plan team members,
5. implementing the isp as written
6. supervising, monitoring and evaluating services provided to the individual
7. reviewing, signing and dating monthly documentation of an individual's participation and progess towards outcomes
8. reporting a change related to the individuals's needs to the sc or plan lead as applicable, and plan team members
9. reviewing the isp with the individual as required under 186
10. documenting the review of the isp as required under 186
11. providing the documentation of the isp review to the sc or plan lead as applicable, and plan team members under 186(d)
12. informing plan team members the option to decline the isp review documentation as required under 186e
13. recommending a revision to a service or outcome in the isp as provided under 186c4
14. coordinating the services provided to the individual
15. coordinating the training of direct service workers in the content of health and safety needs relevant to each individual
16. developing and implementing provider services as required under 188 | The program specialist shall be responsible for the following: Providing the assessment as required under § 2380.181(f) (relating to assessment). | Please see Attachment #13 for a copy of the Staff #1's training done on 11/7/2017 including training on providing the assessment as required under § 2380.181(f) (relating to assessment). Effective 11/7/2018, the Program Specialist will be trained on and responsible for providing the assessment as required under § 2380.181(f) (relating to assessment). |
11/07/2018
| Implemented |
| 2380.33(c)(2) | Staff/program specialist #1 received her BS in psychology and sociology in 5/2015 and did not have 2 full years of experience working with individuals with developmental disabilities. She worked from June 2015-april 2017 and then was hired in 6/19/17 as a ps. | A program specialist shall have one of the following groups of qualifications:(2) A bachelor's degree from an accredited college or university and 2 years of work experience working directly with persons with disabilities. | Staff #1 received 2 bachelor's degrees in psychology and sociology in May 2015 from an accredited university and has 2+ years of working experience working directly with persons with disabilities. Effective 11/7/2018, Program Specialists shall have one of the following groups of qualifications:(2) A bachelor's degree from an accredited college or university and 2 years of work experience working directly with persons with disabilities. |
11/07/2018
| Implemented |
| 2380.36(e) | Staff 1 started at the Hollidaysburg location when it opened on 11/7/17. There is no documentation that she was trained in fire safety specific to this location until 6/15/18. There's no documentation that the fire safety training was completed by a fire safety expert. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Please see Attachment #11 for a copy of Staff #1's fire safety training conducted on 8/31/2017. Effective 11/7/2018, fire safety training for the Program Specialist will be conducted annually during the fire safety inspection by the fire safety expert. The training will include 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. |
| Implemented |
| 2380.36(h) | No content kept for staff 1 for staff meeting 9/18/17 in relation to insulin diabetes. | 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. | Please see Attachment #12 for a copy of the sign in sheet for staff meeting held on 9/18/2017 and the insulin diabetes training content. Effective 11/7/2018, 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. |
11/07/2018
| Implemented |
| 2380.59(b) | Women's bathroom water temperature registered 135 degrees. Kitchen registered 135 degrees. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The hot water heater thermometer at the First United Methodist Church of Hollidaysburg has been lowered with a limit of 110°F. Effective 11/7/2018, hot water temperatures in areas accessible to individuals will not exceed 120°F. |
11/07/2018
| Implemented |
| 2380.84 | No documentation of the 2018 fire safety inspection. Last inspection 8/1/17. | The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept. | Please see Attachment #10 for a copy of the 2018 Fire Safety Inspection done on 7/20/2018. Effective 11/7/2018, documentation of the date, source, and results of the fire safety inspection shall be kept. |
11/07/2018
| Implemented |
| 2380.89(c) | No documentation of the 2018 fire safety inspection. Last inspection 8/1/17. | 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 was operative. | Please see Attachment #9 for a copy of the fire drill log indicating fire drills conducted on 4/25/2018. Effective 11/7/2018, a fire drill will be conducted monthly and written record shall be kept of the date, time, and the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. |
| Implemented |
| 2380.89(g) | Past participant/Individual #1 refused to exit during the 4/25/18 fire drill. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Please see Attachment #9 for a copy of the fire drill log indicating fire drills conducted on 4/25/2018. Effective 11/7/2018, a fire drill will be conducted monthly and individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. |
11/07/2018
| Implemented |
| 2380.111(c)(1) | Individual 's 10/20/17 physical exam did not include a medical history. (ID only diagnosis listed). Individual 2's 3/26/18 physical examination form does not include a medical history. It only indicates "developmental disabilities." According to her 3/27/17 physical exam she is diagnosed with id, IBS, c/o diarrhea with some fecal incontinence, h/o constipation and agree with concern for overflow, postural hypotension, heavy menses, anxiety/depression, syncope and collapse, chronic migraine without auroa without status migrainousis, diarrhea unspecified | The physical examination shall include: A review of previous medical history. | Individual #1's 10/20/17 physical exam has been faxed to her doctor's office on 11/7/2018 for completion. Please see Attachment #17 for a copy of the fax receipt. The doctor will include a review of her previous medical history. Individual #2's 3/21/2017 physical exam has been faxed to her doctor's office on 11/5/2018 for completion. Please see Attachment #18 for a copy of the fax receipt. The doctor will include a review of her previous medical history. Effective 11/7/2018, each individual's physical exam will include a review of their previous medical history. |
| Implemented |
| 2380.111(c)(3) | Individual 1's 10/20/17 physical exam did not include immunizations. This section was blank.
Individual 2's 3/26/18 physical examination form does not include immunizations. The field is left blank. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1's 10/20/17 physical exam has been faxed to her doctor's office on 11/7/2018 for completion. Please see Attachment #17 for a copy of the fax receipt. The doctor will include her immunization record. Individual #2's 3/26/18 physical exam has been faxed to her doctor's office on 11/5/2018 for completion. Please see Attachment #18 for a copy of the fax receipt. The doctor will include her immunization record. Effective 11/7/2018, each individual's physical exam will include immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. |
| Implemented |
| 2380.111(c)(7) | Individual 1's 10/20/17 physical exam did not include health maintenance needs or need for blood work. These sections were 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. | Individual #1's 10/20/17 physical exam has been faxed to her doctor's office on 11/7/2018 for completion. Please see Attachment #17 for a copy of the fax receipt. The doctor will include an assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals. Effective 11/7/2018, each individual's physical exam will include an assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals. |
| Implemented |
| 2380.111(c)(9) | Individual 2's 3/27/17 and 3/26/18 physical examination forms do not include her allergies of seasonal allergies. This was listed on her identification form. | The physical examination shall include: Allergies or contraindicated medication. | Individual #2's 3/21/17 and 3/26/2018 physical exams have been faxed to her doctor's office on 11/5/2018 for completion. Please see Attachment #18 for a copy of the fax receipt. The doctor will include her full list of allergies. Effective 11/7/2018, each individual's physical exam will include allergies or contraindicated medications. |
| Implemented |
| 2380.111(c)(10) | Individual 1's 10/20/17 physical exam did not include information pertinent to diagnosis and treatment in case of an emergency. This section was blank.
Individual 2's 3/26/18 physical examination form does not include information pertinent to diagnosis/treatment. The form indicated none. However according to her 3/27/17 physical examination she has mood swings, syncope, and migraines. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's 10/20/17 physical exam has been faxed to her doctor's office on 11/7/2018 for completion. Please see Attachment #17 for a copy of the fax receipt. The doctor will include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's 10/26/18 physical exam has been faxed to her doctor's office on 11/5/2018 for completion. Please see Attachment #18 for a copy of the fax receipt. The doctor will include information pertinent to diagnosis and treatment in case of an emergency. Effective 11/7/2018, each individual's physical exam will include medical information pertinent to diagnosis and treatment in case of an emergency. |
| Implemented |
| 2380.111(c)(11) | Individual 1's 10/20/17 physical exam did not include special diet instructions. This section was blank. | The physical examination shall include: Special instructions for an individual's diet. | Individual #1's 10/20/17 physical exam has been faxed to her doctor's office on 11/7/2018 for completion. Please see Attachment #17 for a copy of the fax receipt. The doctor will include special instructions for her diet. Effective 11/7/2018, each individual's physical exam will include special instructions for an individual's diet. |
| Implemented |
| 2380.113(c)(3) | Staff 1's 6/17/17 physical exam form did not indicate if she was free from communicable disease. The field was left blank. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases 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, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | Please see Attachment #15 for a copy of Staff #1's completed physical. Effective 11/7/2018, all new hire's physical exam forms will be checked for completion on their first day of work, ensuring the physical includes a signed statement that the person is free of 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, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. |
| Implemented |
| 2380.113(c)(4) | Staff 1's 6/17/17 physical exam form did not indicate if she was clear of any medical problems which might interfere with the health, safety, or well-being of other individuals. The field was left blank. | The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals. | Please see Attachment #15 for a copy of Staff #1's completed physical. Effective 11/7/2018, all new hire's physical exam forms will be checked for completion on their first day of work, ensuring the physical includes information of medical problems which might interfere with the safety or health of the individuals. |
| Implemented |
| 2380.132(12) | Day program provides meals on Fridays. Dishes are hand washed. Mechanical Dishwasher not used. | If the facility provides or arranges for meals for individuals, the following requirements apply: Utensils used for eating, drinking, preparation and serving of food or drink shall be washed after each use by a mechanical dishwasher or by a method approved by the Department of Environmental Resources. | Please see Attachment #8 for a copy of the staff manual update memo on 11/5/2018, which indicates that utensils used for eating, drinking, preparation and serving of food or dink shall be washed after each use by a mechanical dishwasher or by a method approved by the Department of Environmental Resources, and that single serve tableware may also be used. Effective 11/5/2018, the CARES of Central Pa Staff Manual has been updated to reflect that utensils used for eating, drinking, preparation and serving of food or drink shall be washed after each use by a mechanical dishwasher or by a method approved by the Department of Environmental Resources, and that single serve tableware may also be used. |
| Implemented |
| 2380.171(b)(3) | Individual #2's record indicated that she had legal guardians but that she was consenting for her own emergency medical consent. Record needs to include name, address and phone number of person designated for emergency medical consent. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Please see Attachment #14 for a copy of the CARES of Central Pa Hollidaysburg Day Program Emergency Fact Sheet for Individual #2 containing the name, address, and telephone number of Danielle Imler, Individual #2's legal guardian and emergency contact. Danielle Imler is able to give consent for emergency medical treatment for Individual #2. Effective 11/7/2018, emergency information for each individual will include the name, address, and telephone number of the person able to give consent for emergency medical treatment, if applicable. |
| Implemented |
| 2380.173(9) | Individual 1's 2/13/18 assessment indicated seasonal allergies. The physical indicated ace inhibitors as an allergy. The ISP indicated seasonal allergies. codeine was listed as a contradicted med. Chronic kidney diagnosis diagnosed in 2018 not on physical exam. all diagnosis in assessment (hypertension, osteoarthritis, anxiety, depression, hyperlipidemia not on physical. ISP indicated diagnosis of gout in 2017.
Individual 2's ISP indicates she has up to 15 minutes of alone time in order to relax or use the bathroom, and other activities as desired at day program however she does not have any alone time at day program or in the community. No documentation of notification to SC to update the ISP by the program specialist. | Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | Please see Attachment #16 for Individual #1's updated Medical Diagnosis and Limitations section of her assessment, updated and sent to her team on 11/5/2018. Individual #1's 10/20/17 and 10/12/2018 physical exams have been faxed to her doctor's office on 11/7/2018 for completion. Please see Attachment #17 for a copy of the fax receipt. The doctor will include all allergies and diagnosis on both physicals. Please see Attachment #2 for a copy of the track changes sent to Individual #2's Support Coordinator on 10/12/18 indicating her level of supervision as a 1:1 and that she does not have any alone time while at day program. The ISP was updated by the Support Coordinator with these changes on 10/15/2018. Effective 11/7/2018, each individual's ISP will be reviewed quarterly for content accuracy and discrepancies. Changes will be made as needed by the Program Specialist. |
| Implemented |
| 2380.181(a) | Individual #1 transferred from another Cares day program. According to PS, assessment was not reviewed for accuracy. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Please see Attachment #3 for Individual #1's annual assessment updated and sent to her team on 2/13/2018. Effective 11/7/2018, each individual will have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. Each individual who transfers from one CARES of Central Pa facility to another will have a new assessment conducted within 60 calendar days after admission to the new facility. |
| Implemented |
| 2380.181(e)(4) | Individual 2's updated assessment on 4/19/18 doesn't include her supervision level needed while out in the community. The assessment describes the staffing for day program. Her 11/30/17 assessment doesn't discuss supervision levels for day program, it only described supervision levels for at home and community. | The assessment must include the following information: The individual's need for supervision. | Please see Attachment #4 for a copy of Individual #2's assessment updated and sent to her team on 10/31/2018 to reflect her supervision level needed both while out in the community and while at CARES of Central Pa Day Program as a 1:1. Effective 11/7/2018, each individual's assessment will include the individual's need for supervision both while at CARES of Central Pa Day Program and while out in the community at day program. |
| Implemented |
| 2380.181(e)(5) | 11/30/17 Individual #2's ISP said she can self administer but also requires current supervision and reminder for when to take medications before meals and also had taken too much medication/ibuprofen in the past. | The assessment must include the following information: The individual's ability to self-administer medications. | Please see Attachment #5 for a copy of the updates made to Individual #2's medication section of her assessment sent to her Support Coordinator on 10/12/2018 along with her track changes (Attachment #2). These changes indicate that Individual #2 is self-medicating. The ISP was updated by the support coordinator on 10/15/2018 to reflect that Individual #2 is able to self-medicate. Effective 11/7/2018, each individual's assessment will include the individual's ability to self-administer medications. |
| Implemented |
| 2380.181(e)(9) | Individual 2's 11/30/17 assessment does not include her diagnosis to IBS, c/o diarrhea with some fecal incontinence, h/o constipation and agree with concern for overflow, postural hypotension, heavy menses, anxiety/depression, syncope and collapse, chronic migraine without auroa without status migrainousis, diarrhea unspecified as described on her 3/27/17 physical exam. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Please see Attachment #6 for a copy of the updates made on 11/2/2018 to Individual #2's annual assessment to reflect her full list of diagnoses. These updates were sent to her team on 11/2/2018. Effective 11/7/2018, each individual's assessment will include documentation of the individual's disability, including functional and medical limitations. |
| Implemented |
| 2380.181(e)(13)(v) | Individual 2's 11/30/17 doesn't have current level of recreation skills, just includes activities with an "x". | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Please see Attachment #7 for a copy of the updates made on 11/2/2018 to individual #2's annual assessment recreation section to reflect her progress over the last year and current level of recreation. The changes were sent to her team on 11/2/2018. Effective 11/7/2018, each individual's assessment will include the individual's progress over the last 365 calendar days and current level in regards to recreation. |
| Implemented |
| 2380.183(4) | Individual #2's ISP doesn't include her level of supervision needed in the community | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | Please see Attachment #2 for a copy of the track changes sent to Individual #2's Support Coordinator on 10/12/18 indicating her level of supervision needed in the community. The ISP was updated in HCSIS by the Support Coordinator with these changes on 10/15/2018. Effective 11/7/2018, each individual's ISP will be reviewed quarterly for accuracy and changes will be made as needed by the Program Specialist. Each individual's ISP will outline specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. |
| Implemented |
| 2380.186(c)(2) | Individual 1's 8/2/18, 5/10/18 2/13/18, 11/20/1 ISP reviews did not review his unsupervised time at day program. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Please see Attachment #1 for a copy of the email sent to Individual #1's team lead at Skills and her Support Coordinator stating that she does not have any unsupervised time while at CARES of Central Pa Day Program or while in the community at day program. Effective 11/7/2018, all CARES of Central Pa's quarterly meeting notes will reflect a restrictions and supervision section, that will include each individual's staffing requirements and unsupervised time while at day program. |
| Implemented |