| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.16 | The CEO, Staff #1, indicated during licensing that Individual #3 is usually able to ambulate around the program without assistance but may require a wheelchair in the community for long distances. During the onsite inspection on 10/3/18, incident reports for Individual #3 were found. According to the incident report on 6/13//18 and 6/14/18 recorded by CT Home Care staff, Staff #2 and Staff #1 respectively, Individual #3 was subject to neglect and lack of medical treatment.
The incident report on 6/13/18 indicated "In about 8:45am this morning I was with other residents and my co-workers at work and I had a noise coming from the door and I waited to see if someone was coming in but after 3 seconds I did not see anyone, so I stood up and peep the door only to see individual #3 on the floor with his driver getting him up. So, I walk up to them and ask him what happen he told me individual #3 tripped and fall as he opened the door. I said to him he needs support when walking. And I ask him how he fall he said with his shoulders and part of his back head-neck."
There's no indication that Individual #3 received any medical support or follow up from this fall on his shoulder, back, head and neck.
According to the 6/14/18 incident report, "follow-up from incident on 6/13/18. KHS (Keystone Human Services) staff took individual #3 to the ER on 6/13/18. On 6/14/18 individual #3 returned to the day program. KHS said he was in pains and she gave him Tylenol. Individual #3 was unable to walk; a wheelchair was used. Later during the day, around 2:30pm-3:00pm when I tried to change Individual #3, I noticed his left-side ankle was swollen. He couldn't stand nor walk. I had to change him on the wheelchair as he was wet soaked. Individual #3 stood up only for seconds to have his pants pulled down and up. When support staff came to pick him up, I informed them of the swollen ankle. Me and the support staff had to manually lift and carry individual #3 from the wheelchair into the car."
Tylenol was never available to Individual #3 while at day program for any pain he was in due to his swollen ankle. There isn't staff that are medication trained to administer medications while at day program. At the time of licensing, CEO did not have any documentation to indicate that they received any documentation to indicate if Individual #3's ankle was broken or any discharge paperwork from his supposed ER visit on 6/13/18. The day program did not have any documentation of medical follow up for his swollen ankle. CEO was aware of Individual #3 being in pain and he was unable to walk immediately upon his arrival to program; however Individual #3 stayed at program all day. Day program did not contact medical professionals or his residential staff to have him evaluated again. CEO noticed Individual #3 was unable to stand or walk, yet she had Individual #3 stand to change him.
According to day program attendance records, Individual #3 attended program from 8:50am-2pm on 6/13/18. He stayed at the day program the entire day when the program staff was aware that he fell and hit his head. The 6/14/18 attendance record indicated that Individual #3 attended program from 8:39am-2:59pm.
According to Incident #8440528 entered on 6/13/18 by Keystone residential staff "Individual #3 was discharged from the ER at approximately 2:50pm with fall prevention and home safety tips to prevent falls in the future. The staff will continue to follow Keystone's fall protocol as written."
The day program provider did not have a fall prevention plan in place for Individual #3, didn't have discharge instructions from the fall on 6/13/18, and didn't have tips to prevent falls in the future.
Also, according to the incident #8440528, "A fall screening checklist was completed as a result of the fall. A risk mitigation plan was developed, and staff were trained on 7/12/2018." The day program facility did not inquire with residential staff if there were any fall plans in pl | This applies to abuse occurring at the facility.
Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse.
Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview
| Staff #1 has submitted incident report and suspended herself from providing direct support services.
Certified investigator was contacted. Report from CI attached.
Policy developed and staff trained to prevent future incidents.
Staff #1 trained in abuse and neglect. Certificate attached. |
10/31/2018
| Implemented |
| 2380.17(c)(1) | EMS arrived at the facility on 8/29/18 for Individual #2 due to behaviors. An incident report was not entered. | The facility shall orally notify, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs: The county mental health and intellectual disability program of the county in which the facility is located if the individual involved in the unusual incident has mental illness or intellectual disability. | Program Specialist/ CEO wasn't aware that incident report had to be submitted at all times when EMS was called into the facility- even though no actions were done by EMS.
Individual #2 was not part of the individuals ratio at the time of the inspection. Individual #2 was discharged from program effective 9/28/2018. The SC Supervisor from CMU was made aware of the incident by email.
Incident report was submitted on 10/5/2018.
Program specialist/CEO has taken an incident management training on myodp.org. Certificate is available.
Moving forward; PS/CEO will keep track of all incidents using an incident management spreadsheet. Incident management is part of the Agency's QMP. Attachment #50.
Incident management is part of staff programming and implementation training. Attachment #49. |
10/05/2018
| Implemented |
| 2380.17(c)(2) | EMS arrived at the facility on 8/29/18 for Individual #2 due to behaviors. An incident report was not entered. | The facility shall orally notify, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs: The funding agency. | Program Specialist/ CEO wasn't aware that incident report had to be submitted at all times when EMS was called into the facility- even though no actions were done by EMS.
Individual #2 was not part of the individuals ratio at the time of the inspection. Individual #2 was discharged from program effective 9/28/2018. The SC Supervisor from CMU was made aware of the incident by email. Attachment of email available.
Incident report was submitted on 10/5/2018.
Program specialist/CEO has taken an incident management training on myodp.org. Certificate is available.
Moving forward; PS/CEO will keep track of all incidents using an incident management spreadsheet. Incident management is part of the Agency's QMP.
Incident management is part of staff programming and implementation training. |
10/05/2018
| Implemented |
| 2380.17(c)(3) | EMS arrived at the facility on 8/29/18 for Individual #2 due to behaviors. An incident report was not entered. | The facility shall orally notify, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs: The appropriate regional office of intellectual disability. | Program Specialist/ CEO wasn't aware that incident report had to be submitted at all times when EMS was called into the facility- even though no actions were done by EMS.
Individual #2 was not part of the individuals ratio at the time of the inspection. Individual #2 was discharged from program effective 9/28/2018.
The SC Supervisor from CMU was made aware of the incident by email.
Incident report was submitted on 10/5/2018.
Program specialist/CEO has taken an incident management training on myodp.org. Certificate is available. attachment #48.
Moving forward; PS/CEO will keep track of all incidents using an incident management spreadsheet. Incident management is part of the Agency's QMP. Attachment #50.
Incident management is part of staff programming and implementation training. Attachment #49. |
10/05/2018
| Implemented |
| 2380.32(b)(2) | The CEO, Staff #1, is responsible for admission and discharge of individuals. Individual #3 has been attending the program since 9/14/18 and the facility does not have many of the required documents at program. His physical form does not include a tb skin test, past medical history, tetanus/immunizations and physical limitation to include his recent broken ankle that he requires assistance to walk on uneven surfaces. His record didn't include an ISP, emergency contact, emergency medical consent, documentation of disabilities, a communication iPad devise isn't available at program for him to communicate with staff, eye color, dated photo, hair color, identifying marks, religious affiliation, primary language, and fire safety training.
According to CEO, Individual #2 was discharged however the facility did not have documentation to indicate appropriate discharge. The facility was not providing behavior support services to assist Individual #2 while she was at the facility. Individual #2 needs behavioral supports to address yelling and screaming at staff, attempting to hit and push staff, pushing chairs, crying and reluctance to transition from activities and to go home or return to program after an outing. | The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Admission and discharge of individuals. | Staff #1 is responsible for admission and discharge into the program, and for conducting all intake interviews.
Staff #1 didn't conduct the required intake interview to ensure that all information was submitted.
Staff #1 sent out information to Individual #3 family and completed package was resubmitted per fax on 10/10/18. Attachment #48.
Individual #3's Ipad was in the program; he had it in his back bag. He brought it out when staff asked him about it, and is now currently using it. Furthermore, staff provided Individual #3 with a pen and paper, through which he was able to communicate with others. This information was shared with the inspectors.
SC was informed of individual #2 discharge and a 30 day notice was provided.
Staff #1 had requested behavioral support services for Individual #2 approximately month after she started attending the program. Emails attached. #47. Behavioral services was provided late August and early September from Cornerstone BS. Attachment #46- service notes from behavioral support.
Per directions from inspectors, Agency informed SC that services would resume and that Agency will continue working with BS to work on transition goals.
Future: Discharge policy has been developed and implemented. Staff #1 will be responsible for implementation and monitoring. #45.
Individual #2 had 30 days discharge notice which was submitted to SC and Sc supervisor on 8/29/18. This information was provided to the |
10/25/2018
| Implemented |
| 2380.33(b)(2) | Program Specialist Staff #1 did not complete an assessment for individual #4. Her date of admission was 7/31/18. | The program specialist shall be responsible for the following: Providing the assessment as required under § 2380.181(f) (relating to assessment). | It is the responsibility of the Program Specialist to conduct 2380 assessments within 60 days and 1 year.
The due date for Individual #4's 60 day assessment was on 9/31/2018. But this wasn't completed on time.
The Program Specialist has submitted an updated 2380 assessment #17. Included in the assessment is the life time medical history.
Future: Program Specialist has obtained a calendar to enable her to track the due dates for the 2380 assessments going forward. |
10/25/2018
| Implemented |
| 2380.33(b)(17) | INDIVIDUAL #2 IS CURRENTLY DIAGNOSED WITH INTERMITTENT EXPLOSIVE DISORDER AND PERVASIVE DEVELOPMENTAL DISORDER. SHE MAY BECOME PHYSICALLY AGGRESSIVE, MAY PULL HAIR, BANG HER HEAD, CRY, SCREAM THROW HERSELF TO THE FLOOR. INDIVIDUAL #2 IS IN NEED OF BEHAVIORAL SUPPORTS TO ADDRESS THE FOLLOWING NEEDS: YELLING AND SCREAMING AT STAFF, ATTEMPTING TO HIT AND PUSHING STAFF, AND PUSHING CHAIRS, CRYING AND RELUCTANCE TO TRANSITION FROM ACTIVITIES AND TO GO HOME OR RETURN TO PROGRAM AFTER AN OUTING. CHOICE OF PROVIDER WAS OFFERED, AND INDIVIDUAL #2 SELECTED CORNERSTONE AGENCY WHO WILL COMPLETE A FUNCTIONAL BEHAVIOR ASSESSMENT, WRITE BEHAVIOR SUPPORT PLAN, CONDUCT PLAN IMPLEMENTATION, STAFF TRAINING, AND CONSULTATION AS EFFECTIVE JULY 23, 2018 (ISP UPDATED 6/20/18). CEO/PS FAILED TO ENSURE THIS HAPPENED. BEHAVIORAL SUPPORTS WERE NEEDED PRIOR TO INDIVIDUAL #2 ADMISSION TO PROGRAM FOR A BETTER CHANCE AT A SUCESSFUL TRANSISTION. AT THIS TIME INDIVOIDUAL #2 IS NOT ATTENDING DAY PROGRAM. STAFF #1 NEVER SAT DOWN TO SPEAK WITH INDIVIDUAL #2 ABOUT LEAVING THE PROGRAM. | The program specialist shall be responsible for the following: Coordinating the services provided to an individual. | Individual #2 started in the program after which the PS/CEO requested behavioral support because of some behaviors exhibited by individual #2. There are furthermore email trails that documents that Cornerstone didn't get back to the Team on the required timeframe as stated on the ISP. There are email trails that showed that both the program and the KHS home contacted the SC to inquire about what was happening with the BS services. There are email trails that document how the PS/CEO coordinated these services.
BS services couldn't be provided to individual prior to attending services due to new regulations that state that BE services must be provided at the day program while the individual is attending the program. This is the information that Cornerstone shared with us.
PS informed SC of termination of individual #2 service but didn't have a formal meeting with individual#2 to inform her of the decision.
Current actions: CEO/PS has contacted the SC to work on transitioning the Individual #2 back to the program, per recommendations of the inspectors. Email is available.
To prevent further reoccurrence, PS has taken training on ISP implementation on myodp. Certificates are available. |
10/02/2018
| Implemented |
| 2380.33(b)(18) | Individual #1 is type II diabetic, takes diabetes medication daily, and requires to have his blood sugar checked daily. There was no training provided to any direct support staff on diabetes and sign/symptoms of low and high blood sugar, etc. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | It is the responsibility of Program Specialist to train DSP on health and safety concerns of individuals.
Program Specialist didn't provide the required training.
Correction: Attachment # 44. Training materials for health and safety.
Attachment #44. Staff training sign in sheet.
Future: Program Specialist shall review on a quarterly basis the health and safety training needs. |
10/25/2018
| Implemented |
| 2380.33(c)(2) | Staff #4 was hired as a program specialist on 3/26/18, her college degree or transcripts were never verified by the agency at any time during her employment. There were no transcripts or copies of her degree on file during the inspection. | 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 #4 was no longer working with Agency at the time of inspection.
CEO on hiring the Staff #4 relied on her BSW degree as stated on her resume. Staff #4 started on her resume that she graduated with a BSW. CEO was aware of the graduation. CEO should have required transcripts as per requirements.
As staff #4 resigned in April from her position of PS, Agency isn't able to obtain transcripts.
Going forward, CEO has developed HR policy # 33A- Staff Qualifications, which clearly states that CEO will be responsible of verifying staff qualifications and ensuring for compliance.
Staff qualifications and employees' files shall be reviewed when a new staff is hired. |
10/16/2018
| Implemented |
| 2380.36(a) | Staff #1 8/1/2017 and Staff #2 4/16/2018 did not have training in daily operations of the facility and policy and procedures. Staff #2 did not have training in her responsibilities. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | Staff #1 is responsible for implementation and adherence to 2380 regulations. Staff #1 was providing oral/verbal training to staff prior on daily operations of facility and policy and procedures. Unfortunately, there was no record of the training materials.
Correction: Staff #1 and 2 has been trained on daily operations of the facility and policy and procedures. Sign in sheets attachment #37.
Future: CEO will ensure that all staff are trained. She will review the training folder every month to ensure compliance with this requirement.
As proof of evidence, sign in sheets for all staff training include: Attachment # 37. |
10/31/2018
| Implemented |
| 2380.36(d) | Staff #1 and Staff #2 did not have training in program planning and implementation. | Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | Staff 1 and 2 have completed ODP training and CPS trainings.
Staff #1 and 2 didn't complete 2380 specified program planning and implementation.
Staff #1- per recommendations from 2380 inspectors completed ISP implementation trainings on myodp. Attachment #39.
Attachment #37. Training sign in sheet that includes information that all staff are now trained in program planning and implementation.
Going forward, Staff #1 will review training folder on a monthly basis to ensure that all staff are trained according to regulations. |
10/31/2018
| Implemented |
| 2380.58(a) | The first aid room was missing baseboard in multiple places throughout the room. They were missing two electrical outlet covers and one electrical outlet was exposed. Part of a wall in the first aid room had pealing wallpaper. | Floors, walls, ceilings and other surfaces shall be in good repair. | The CEO is responsible to ensure that the facility is neat and structures are in good state. It was an oversight of the CEO.
CEO has performed required changes. Receipt from home depot is attached.
Going forward, the CEO will inspect the facility on a monthly basis to ensure that everything is in good repair. Attachment #35. |
10/31/2018
| Implemented |
| 2380.59(b) | The water at the facility was 128.9 degrees Fahrenheit. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | CEO wasn't checking the water temperature.
CEO contacted building maintenance and the water temperature was reset at 180 degrees Fahrenheit. Email exchange available. Attachment #34a.
Going forward, water temperature shall be checked by the CEO or staff performing fire drill. Fire drill form has been updated to include information about water temperatures. Attachment #34.
. |
10/05/2018
| Implemented |
| 2380.67(a) | There were 2 broken chairs in the first aid room. There was another wooden chair in the first aid room with a ripped seat cushion. | Furniture and equipment shall be nonhazardous, clean and sturdy. | It is the responsibility of the CEO to ensure that furniture and equipment are non hazardous.
The furniture were moved to the first aid room but were not being used by the individuals.
The CEO removed the furniture and they were dumped at the dumpster.
Going forward, the CEO will do monthly scanning of the facility to ensure that everything is ok. Attachment #35. |
10/26/2018
| Implemented |
| 2380.70(d) | There was no thermometer in the first aid kit. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | It is the CEO's responsibility to ensure that all materials in the first aid kit are available.
The thermometer was bought day 2 of the inspection: 10/3/2018. The inspectors were informed of that.
Going forward, the fire drill form has been updated to include a spot to check for elements of the first aid kit. Attachment #34.
Every month, during the fire drill the CEO will ensure that all elements on the fire drill form are checked: first aid kit, water temperature, etc. |
10/26/2018
| Implemented |
| 2380.83(a) | The written emergency evacuation plan did not include individual's responsibilities or the means of transportation to the emergency evacuation site. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. | It is the CEO's responsibility to ensure that all policies are compliant with 2380 regulations.
The written emergency policy included staff responsibilities but not individual's responsibilities.
The emergency evacuation plan was been updated to include individual's responsibilities, staff responsibilities, and means of transportation.
Attachment #33.
The CEO will review policies and procedures as part of ongoing QMP annually. |
10/26/2018
| Implemented |
| 2380.89(c) | The fire drill held on 8/20/18 did not include the time of the drill. The fire drill held on 7/19/18 only indicated "1:00" but did not indicate AM or PM. The facility has smoke detectors throughout the facility that are not connected to the fire alarm system. The facility is not checking if the smoke detectors are operative during the monthly fire drills. | 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. | It is the CEO's responsibility to ensure fire drills are conducted according to the 2380 regulations. Attachment #34 shows a fire drill conducted per regulations. The fire drill form has a section to ensure that smoke detectors are checked every month during fire drills.
Smoke detectors were installed by the fire safety expert during the annual fire safety inspection.
Smoke detectors are installed on all areas of the facility and are functioning.
The CEO will monitor and review all fire drill records on a monthly basis henceforth to ensure compliance with the requirements. |
10/31/2018
| Implemented |
| 2380.89(d) | During the fire drill on 10/3/18 Individual Staff #3 did not evacuate in 2.5 minutes. He made it out the front door in 2 minutes and 54 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | It is the responsibility of the CEO to ensure that all individuals evacuate within 2.5 minutes.
The facility has performed drills and Individual staff #3 as evacuated within 2.5 minutes. Fire drill form attached #34.
Ongoing fire drills will be performed and repeated should any individual not evacuate within the required 2.5 minutes.
CEO will review fire drills on a monthly basis to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.89(e) | The fire drills held for the year only indicated that the back door was used during an evacuation once, all other times the front door was utilized. | Alternate exit routes shall be used during fire drills. | It is the CEO's responsibilities to ensure that fire drills are conducted according to the regulations.
During the annual fire drill inspection by the fire safety inspector, the facility was informed to only use one exit as a precaution in case the fire. The inspectors instructed the facility to use both exits but to use the same gathering place which is located at the front of the building, next to front exit.
The fire drill form is attached #34 with the fire drill conducted for the month of October using the back door exit.
The CEO will monitor and review the fire drill forms to ensure that both doors are use alternatively during monthly fire drills. |
10/31/2018
| Implemented |
| 2380.89(h) | The facility did not use the fire alarm system installed in their program for their fire drills throughout the year. They were using a single smoke detector kept in the CEO's, Staff #1, office desk drawer. | A fire alarm shall be set off during each fire drill. | It is the CEO's responsibilities to ensure that the facility is compliant with 2380 regulations.
The fire inspector from dauphin county recommended during the annual fire drill that the facility use a smoke detector during the fire drill in lieu of setting off the fire alarm and contacting the fire department.
The CEO is now aware that the fire alarm system needs to be set off during fire drills.
See attachment #34.
Attachment #34 also includes information of actual fire drill performed.
The CEO will ensure during monthly review of fire drill records that the actual fire drill system was used and it was functional. |
10/26/2018
| Implemented |
| 2380.111(a) | Individual #2's physical is not current. It was last completed 8/31/2017. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | It is the CEO's responsibility to ensure compliance with 2380 regulations.
The CEO is responsible to ensure that all documents are current during the intake interview.
CEO has emailed residential staff to request for updated physical form. Attachment #24.
To be noted that Individual #2 was not under facility's ratio during inspection.
Going forward, CEO will ensure compliance be reviewing records monthly. |
10/18/2018
| Implemented |
| 2380.111(c)(10) | Individual #2's physical 8/31/2017 did not include Info pertinent to diagnosis in case of Emergency; it was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | It is the CEO's responsibility to ensure that all documentation are accurate during intake.
CEO has contacted residential staff to submit updated physical information. #24.
Henceforth, during monthly individual reviews, CEO will ensure that all documentation are current and accurate. |
10/31/2018
| Implemented |
| 2380.171(b)(1) | Individual #1's record does not include the name, address, phone number and relationship of the person designated to be his/her emergency contact. | Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | It is the CEO's responsibility to ensure compliance with all 2380 regulations and to ensure all information is accurate during the intake interview.
CEO has updated information. Attachment #29.
Attachment #29 also contains evidence of all other individual's listed on the POC whose records were not complete.
Henceforth, the CEO will review individual's records monthly to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.171(b)(3) | Individual #1's record does not include the name, address and phone number of the person designated to give medical consent during a medical emergency. This was blank. | 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. | It is the CEO's responsibility to ensure compliance with all 2380 regulations and to ensure all information is accurate during the intake interview.
CEO has updated information. Attachment #29.
Attachment #29 also contains evidence of all other individual's listed on the POC whose records were not complete.
Henceforth, the CEO will review individual's records monthly to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.172(a) | Individuals' records were intermingled throughout the program. There was one binder that contained all the individuals' ISP reviews. Another binder contained all individual's face sheets with demographics and emergency information. Another binder contained all participant's physicals. | A separate record shall be kept for each individual. | It is the CEO's responsibility to ensure that all records are kept separate.
The CEO has separate folders for different records and this lead to the inspectors reviewing all individuals on the roster (which were not included in the original 2 records they had requested to review)..
Binders were bought and individuals now have records that contain all there information stored in one binder. Receipt of binders purchase isn't available but picture of binders has been submitted as attachment #26..
Henceforth, the CEO will ensure that individual records are maintained in binders. |
10/05/2018
| Implemented |
| 2380.173(1)(ii) | Individual #2 record did not include her weight, height. | 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. | It is the responsibility of the CEO to ensure that all documentation are available and current during the intake process.
CEO will conduct quarterly review of individuals' records to ensure compliance with the regulations.
Individual #2 wasn't attending the program again at the time of inspection. Email #24 has been sent to residential staff requiring information be updated prior to individual retuning to the program. |
10/31/2018
| Implemented |
| 2380.173(1)(ii) | Individual #5, Individual #6, Individual #3, Individual #7, Individual #8, Individual #1, Individual #9, Individual #10, Individual #11 records all indicate that their eye color is black. Black is not a medically recognized eye color.
Individual #1's record did not contain identifying marks. This was blank on the face sheet and not noted nowhere else throughout his record. | 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. | It is the responsibility of the CEO to ensure that all documentation are available and current during the intake process.
Attachment # 29. Updated emergency record information for the individuals.
CEO will conduct quarterly review of individuals' records to ensure compliance with the regulations.
Individual #2 wasn't attending the program again at the time of inspection. Emergency contact form sent to residential staff to fill prior to her return to the program.
Individual #1's residential staff said they were not aware of any identifying marks.
Individual #7's mom said he didn't have any identifying marks. |
10/31/2018
| Implemented |
| 2380.173(1)(iv) | Individual #2 record did not include her religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | It is the responsibility of the CEO to ensure that all documentation are available and current during the intake process.
Attachment # 29. Updated emergency record information for individuals in the program.
CEO will conduct quarterly review of individuals' records to ensure compliance with the regulations.
Individual #2 wasn't attending the program again at the time of inspection. #24 for evidence that information has been requested prior to her return to the program. |
10/31/2018
| Implemented |
| 2380.173(5(ii) | Individual #1's record didn't include a copy of his annual ISP meeting invitation. | Each individual¿s record must include the following information: A copy of the invitation to: The annual update meeting. | It is the program specialist's responsibility to ensure compliance with 2380 regulations as it pertains to ISPs.
Attachment # 11. Corrective action.
Attachment #31. ISP invitation letters as evidence of correction.
CEO will review individuals' records on a quarterly basis using worksheet. |
10/31/2018
| Implemented |
| 2380.173(6)(ii) | Individual #1's record didn't include a copy of his annual ISP meeting signature sheet. | Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting. | It is the program specialist's responsibility to ensure compliance with 2380 regulations as it pertains to ISPs.
Attachment # 11. Corrective action.
CEO will review individuals' records on a quarterly basis using worksheet. |
10/31/2018
| Implemented |
| 2380.173(9) | Individual #1's face sheet indicated allergies to fresh strawberries, tgel shampoo, and cat hair. An intake form in his record also indicated seasonal allergies. ISP doesn't include allergy to seasonal allergies. His 10/17/17 physical form indicates allergies to seasonal, strawberries, t-gel shampoo, and cats. Individual #1's physical included a diet of kosher, limited carbohydrates. His lifetime medical history in his record indicated he's on a diabetic diet, he should eat sugar free items and low carbohydrates, also follow a kosher diet. His ISP indicates he should follow a low carb/low sugar/kosher diet. His ISP also indicated he should follow a low carb and kosher diet. Individual #1's 10/17/17 physical included diagnosis of rubenstein-taybi syndrome, autism spectrum disorder, diabetes type II and Hyperlipidemia. His assessment indicated he was diagnosed with IDD-Autism, Rubensteing-Taybi Syndrome, Epilepsy and diabetes. His ISP indicates he takes medications for mood stabilizer, high blood pressure, diabetes, allergies, high cholesterol, and anxiety. His ISP indicates he is diagnosed with IDD, Autism, Rubenstein-Taybi syndrome, unspecified anxiety disorder, unspecified mood disorder, hyperlipidemia, and type II diabetes.
Individual #1's 4/6/18 assessment also talks about a participant Individual #3 in relation to what Individual #3's needs are.
Individual #1's ISP indicated that Individual #1 required line of sight supervision in the community; he can spend 10 minutes alone in a vehicle with the windows adjusted appropriately for the weather, but also that Individual #1 left the van while fuel was being paid for and would need to accompany staff when they cannot pay at the pump. His ISP also indicates that arm's length supervision is needed in the community. His 4/6/18 assessment indicated that he required 1:1 supervision in the community, he requires staff within 5 feet of direct observation, but also that staff have Individual #1 within 10 feet while in the community.
Individual #2's 9/3/18 assessment states she will harm herself when she is upset. This is not mentioned in her ISP. The disabilities noted in the assessment do not include pervasive developmental disorder, hyperlipidemia, sensorineural hearing loss, high cholesterol, and cyst on right kidney. Only severe IDD, intermittent explosive disorder and epilepsy was noted. The assessment states Individual #2 has loss of vision in on eye. This is not on her physical 8/31/2017 or in her ISP. The assessment also states "No" for the statement does she take medications for a psych diagnosis. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | It is the program specialist's responsibility to ensure compliance with 2380 regulations as it pertains to ISPs.
Attachment # 11. Email to SC about content discrepancies.
Attachment #20 and 21 corrected assessments.
CEO will review individuals' records on a quarterly basis using worksheet. |
10/31/2018
| Implemented |
| 2380.174(b) | Individual #6 has been attending the program since 4/23/18 and a physical examination for him was not kept at the facility. During licensing on 10/2/18, his residential staff brought a physical to the day program. The physical that was brought wasn't completed until 7/24/18, 3 months after his date of admission to the day program facility. | The most current copies of record information required in § 2380.173(2)¿(11) shall be kept at the facility. | It is the CEO's responsibility to ensure that all documentations are updated and current during the intake process. Updated physical form has been obtained.
CEO will perform quarterly review of individuals' records to ensure compliance with the regulations. |
10/19/2018
| Implemented |
| 2380.176(a) | Individual incident reports and daily documentation of outings, behaviors, and outcomes are not locked when not in use. They are stored in a cabinet in the program room that is accessible to all individuals in the room. | Individual records shall be kept locked when they are unattended. | Individuals' emergency records, medical info and ISP were kept in locked cabinets.
Daily documentation were kept in cabinets that were not locked for staff to assess those during reports.
Cabinets with keys have been purchased and all records are kept severed when not in use.
Attachment #26.
CEO will ensure that all records are securely kept when not in use by daily monitoring of record management process. |
10/05/2018
| Implemented |
| 2380.177 | No release of information. The consent to release photos was signed by Individual #2; however, nothing was checked if she gives consent or not. | Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. | It is the responsibility of the CEO to ensure that all admission documentations are accurate.
Attachment # 24. Correction.
Attachment #25. Evidence that written consent has been collected for other individuals previously.
CEO will perform quarterly review of individuals records henceforth. |
10/31/2018
| Implemented |
| 2380.181(a) | Individual #4 date of admission was 7/31/18 and an assessment was not completed yet at the time of licensing on 10/2/18. | 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. | It is the program specialist's responsibility to ensure that 2380 assessments are completed within 60 days.
Attachment # 17 is the corrected action. Including email that assessment was sent to Team.
Program specialist now has a calendar to record due dates for assessments.
Attachment #19 is the worksheet the CEO will utilize to audit individuals records. |
10/31/2018
| Implemented |
| 2380.181(a) | Individual #2's assessment was late. Her DOA was 6/27/2018 and her assessment was completed 9/3/2018. | 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. | It is the responsibility of the program specialist to ensure that all assessments are completed in a timely manner.
Program specialist didn't complete the assessment within 60 days. assessment was due by 8/27/2018; but it was completed on 9/3/2018.
Program specialist now has a calendar to keep track of due dates on assessments.
CEO will perform a quarterly review of assessments completely using worksheet. Attachment #19. |
10/31/2018
| Implemented |
| 2380.181(e)(3)(ii) | Individual #1's 4/6/18 assessment does not include his current level of communication skills. Individual #1's assessment refers to another individual #3 and what Individual #3's current level of communication skills are. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Staff #4 who completed assessment for individual #1 no longer works for the company.
Current program specialist has completed and updated assessment for Individual #1.Attachment #20.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(e)(3)(iii) | Individual #1's 4/6/18 assessment does not include his current level of personal adjustment skills. Individual #1's assessment refers to another individual #3 and what Individual #3's current level of personal adjustment skills are. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | Staff #4 who completed assessment for individual #1 no longer works for the company.
Current program specialist has completed and updated assessment for Individual #1.Attachment #20.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(e)(4) | Individual #1's 4/6/18 assessment does not include his level of supervision needs in the community. The supervision section of the assessment indicated staff need to be within 5 feet of Individual #1 out in the community. The end of his assessment indicated staff were required to be within 10 feet of him in the community. | The assessment must include the following information: The individual¿s need for supervision. | Staff #4 who completed assessment for individual #1 no longer works for the company.
Current program specialist has completed and updated assessment for Individual #1.Attachment #20.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(e)(9) | Individual #1's 4/6/18 assessment does not include his diagnosis of Diabetes type II, allergies, high cholesterol, anxiety, unspecified anxiety disorder, unspecified mood disorder, hyperlipidemia. Individual #2 The disabilities noted in the assessment do not include pervasive developmental disorder, hyperlipidemia, sensorineural hearing loss, high cholesterol, and cyst on right kidney. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | It is the program specialist responsibility to ensure assessments are completed according to 2380 regulations.
Individual #1.Attachment #20. Updated 2380 assessment.
Individual #2. attachment #21. Updated 280 assessment.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(e)(10) | Individual #1's 4/6/18 assessment does not include a lifetime medical history. The assessment just indicated "note: an updated lifetime medical history must be attached as part of the assessment" but does not indicate that an assessment was completed and attached. There is no lifetime medical history with Individual #2 assessment 9/3/2018. The LMH that was with Individual #2's file was created by Keystone Human Services. | The assessment must include the following information: A lifetime medical history. | It is the program specialist responsibility to ensure assessments are completed according to 2380 regulations.
Individual #1.Attachment #20. Updated 2380 assessment with LMH.
Individual #2. attachment #21. Updated 280 assessment with LMH.
Attachment #22. Completed training on assessments.
CEO will conduct quarterly review of individuals records for compliance.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(e)(13)(i) | Individual #1's 4/6/18 assessment does not include his current health status. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health. | Staff #4 who completed assessment for individual #1 no longer works for the company.
Current program specialist has completed and updated assessment for Individual #1.Attachment #20.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(e)(13)(ii) | It states Individual #2 needs assistance when walking long distances; it does not state what type of assistance. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | It is the program specialist responsibility to ensure assessments are completed according to 2380 regulations.
Individual #2. attachment #21. Updated 280 assessment with LMH.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's 4/6/18 assessment and Individual #2 assessment does not include their current level of recreation skills. There isn't a section for this, nor is it encompassed throughout their assessments. | 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. | It is the program specialist responsibility to ensure assessments are completed according to 2380 regulations.
Current status:
Section 12 of assessment captures Recreational Interests. Section a) states to list specific areas of recreational activities. Section b) Recreational progress Report. Section b) specifically list regulations 2380.181 (e) (13) (v).
I am not sure if it was an oversight from the inspectors.
Individual #1.Attachment #20. Updated 2380 assessment with LMH.
Individual #2. attachment #21. Updated 280 assessment with LMH.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.181(f) | The program specialist/CEO, Staff #1, indicated that she is aware that she has not sent any participant's assessments to any team members. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | It is the program specialist responsibility to ensure assessments are completed according to 2380 regulations.
Individual #1 and Individual #2 . .Attachment #23. Assessment emails as evidence of present and future correction action.
CEO will conduct quarterly reviews of individual records to ensure compliance with regulations. |
10/31/2018
| Implemented |
| 2380.183(3) | Individual #1's ISP does not include a method to evaluate his Socialization outcome in his ISP. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | It is the responsibility of the program specialist to ensure compliance with 2380 regulations.
The Program specialist has emailed the SC with recommended methods of evaluating Individual #1's ISP outcome. Attachment #11.
CEO will review individual's records on a monthly basis to ensure compliance. |
10/31/2018
| Implemented |
| 2380.183(4) | Individual #1's ISP doesn't include his level of supervision needs for day program or when in the community with day program. | 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. | It is the program specialist's responsibility to ensure compliance with 23
80 regulations.
The ISP for individual #1 contains level of supervision while under the care of the residential home; but not while with the day program.
Email has been sent to SC to add that information. Attachment # 11.
Attachment #4 program specialist training on outcomes.
Attachment #2 worksheet that will be utilized by the CEO during quarterly audits of individuals records. |
10/31/2018
| Implemented |
| 2380.183(5) | Individual #1's ISP does not include a protocol to address his social, environmental and emotional needs related to his behaviors at day program or the psychiatric diagnosis for which he is prescribed psychotropic medications. He is prescribed medication for Anxiety, unspecified anxiety disorder, unspecified mood disorder. Individual #1 displays a very wide variety of sensory concerns, elopement, refusals- sitting down in public, anxiety-driven behaviors, physical aggression, screaming, crying, etc.
Individual #2 takes psychotropic medications. There is no SEEN plan in place. | The ISP, including annual updates and revisions under § 2380.186 (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. | It is the program specialist's responsibilities to ensure compliance with 2380 regulations.
Attachment #14 is Individual #1 and Individua #2 SEEN plan.
Attachment #11 is email proof that SEEN plan was sent to SC to include in the ISP.
Attachment #4 Program specialist training certificates.
CEO shall conduct quarterly review of individuals records. Attachment #2. |
10/26/2018
| Implemented |
| 2380.184(c) | There was no ISP signature sheet for Individual #2's ISP meeting held 8/27/2018. | A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet. | It is the responsibility of the program specialist to ensure compliance with 2380 regulations. Sign-in sheet for ISP meeting for Indivual#2 wasn't obtained.
Program specialist has emailed supports coordinator to request a copy of the signature sheet. Attachment # 8.
Program specialist has been trained. Attachment #4.
Attachment #6 is the signature sheet of Individual #9 whose ISP meeting was held 10/4/18- a day after the 2380 inspection. This is to serve as evidence of corrective action and future compliance.
CEO will audit individuals' records to ensure compliance; using attached worksheet #2. |
10/17/2018
| Implemented |
| 2380.186(b) | Individual #1's ISP reviews did not include a handwritten date. The date was prepopulated. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | It is the Program Specialist responsibility to ensure compliance and adherence to 2380 regulations.
The program specialist was entering the dates on the computer as she was drafting the ISP reviews.
Attachment # 1 is the corrected ISP review for Individual #1.
Going forward, program specialist will review individuals ISPs reviews quarterly using the attached worksheet: #2. |
10/25/2018
| Implemented |
| 2380.186(c)(1) | Individual #1's 9/22/18 and 6/22/18 ISP reviews did not include his participation and progress on his socialization outcome. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | It is the program specialist responsibility to ensure that ISP reviews are conducted according to 2380 regulations.
On the ISP review forms, performance/progress were grouped together and the program specialist wasn't capturing the progress information.
ISP reviews for Individual #1 for 9/22/18 and 6/22/18 have been corrected. Program Specialist has taken ISP outcome courses on myodp. Attachment # 4.
Going forward, CEO will audit each ISP review quarterly using the worksheet attachment # 2. |
10/25/2018
| Implemented |
| 2380.186(c)(1) | Individual #2's DOA was 6/27/2018 there was no monthly reviews for July and August 2018. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | It is the program specialist's responsibility to ensure that all monthly reviews are completed in a timely manner.
Program specialist was completing monthly reviews until a 7/25/2018 ODP guideline was issued stating that ODP was recommending providers to do a quarterly review in lieu of monthly reviews. The guideline was shown to the inspectors. The inspectors mentioned that the guidelines were for ODP programing but that 2380 still required monthly progress reviews.
Attachment #5 are the monthly reviews for Individual #2.
CEO shall perform quarterly reviews of individual records using worksheet # 2. |
10/25/2018
| Implemented |
| 2380.186(d) | No documentation of sending ISP reviews to team members for Individual #1. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | ISP's reviews were not sent to ISP team members. Individual #1 ISP review has been sent to his team members. Attachment # 7.
Program Specialist has taken related training. Attachment # 4.
Attachment #8 to serve as evidence that the program specialist has started sending out ISP reviews to team:
Going forward, CEO will review records using audit worksheet: #2. |
10/31/2018
| Implemented |
| 2380.186(e) | Individual #1's team was never offered the option to decline. His team includes residential, himself, SC. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | It is the program specialist's responsibility to ensure that ISP reviews are conducted according to 2380 regulations.
ISP review form didn't contain information about declination. The form has been updated to reflect the option. See attachment # 1.
Program specialist has been trained. Attachment #4.
CEO will conduct quarterly review of individuals' records using worksheet #2. |
10/26/2018
| Implemented |