Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(a) | It could not be determined if a fire drill was completed for October 2019 there was no documentation found in the record. Later on it was provided during inspection but was signed the date of the inspection. Staff explained it was in the vehicle not in the record for review. | An unannounced fire drill shall be held at least once a month. | Unannounced Fire drills will be completed monthly at the direction of the Community Home Supervisor. They will be scanned to Program Specialist to be reviewed for compliance and filed into the CLA Fire Book. If not received by the 25th of each month, the Program Specialist will contact the Community Home Supervisor to ensure the fire drill is completed by months end. The Program Specialist will maintain a spreadsheet of all submitted fire drills. The Program Specialist will sign off on the monthly Fire Drill by month's end. The spreadsheet will be reviewed by the Executive Director to confirm ongoing compliance. Plan in place starting 1/1/20. See Attachment #8 |
01/01/2020
| Implemented |
6400.112(c) | The Fire drill dated 6/6/19 did not indicate what exit was used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Unannounced Fire drills will be completed monthly at the direction of the Community Home Supervisor. They will be scanned to Program Specialist to be reviewed for compliance and filed into the CLA Fire Book. If not received by the 25th of each month, the Program Specialist will contact the Community Home Supervisor to ensure the fire drill is completed by months end. The Program Specialist will maintain a spreadsheet of all submitted fire drills. The Program Specialist will sign off on the monthly Fire Drill by month's end. The Fire Drill form has a corresponding Information Sheet on how to complete a Fire Drill that will be referenced as needed. Plan in place starting 1/1/20. See attachment #4. |
01/01/2020
| Implemented |
6400.141(c)(9) | The physical exam for individual #1 dated 4/17/19, did not include a prostate exam. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual #1 refused prostate exam during physical exam on 4/17/19 prior to admission to Alvarium Healthcare on 6/6/19. Prostate Exam was completed on 11/14/19. Prior to any future admissions into Alvarium Healthcare, the Referral Manager will review physical exam documentation to ensure prostate exam is completed before admission to ensure compliance to regulation and required in advance or admission will be delayed. Compliance for ongoing appointments is tracked by the Nursing Department as well as the Program Specialist. Plan in place starting 1/1/20. See Attachment #3 |
01/01/2020
| Implemented |
6400.168(e) | Initial medication administration for staff member #5 was not provided at inspection, it could not be determined if staff member#5 received medication administration training. current medication administration training in record was 7/11/19. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | 11/7/19 the initial medication administration training documentation was located to verify compliance to this regulation. These documents are being sent to ODP for review via attachment.
The Executive Director will ensure all training documentation is available during annual licensing review to avoid future noncompliance.
All Alvarium staff have training transcripts in RELIAS software system to track and manage annual training requirements. See attachment. This issue is monitored and audited by the training department on an ongoing basis for compliance. See Attachment #2 |
11/07/2019
| Implemented |
6400.181(e)(9) | The assessment did not include documentation of individual#1's disability. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | 11/7/19 - This pending citation was reviewed as part of the ODP Licensing closing. Was prompted to send any information to the licensor regarding this citation as the assessment included "Documentation of the Individual's disability. Including functional and medical limitations." The corresponding regulation numbers were included on the SNAP assessment to further emphasis compliance to this regulation. The assessment directed the viewer to our Lifetime Medical Record were the consumer diagnosis and disabilities were clarified. The assessment was then emailed to the ODP licensor and the consumer AE on 11/7/19 to verify the assessment met the regulation.
All other SNAP assessments were reviewed to confirm this requirement is addressed on the assessment and found to be in compliance.
The Executive Director will ensure the ODP licensor is properly oriented to the contents of this document ongoing.
The SNAP assessment will be closely monitored by the Program Specialist to ensure all aspects of the SNAP Assessment are updated per regulation and discussed during annual ISP meeting. See Attachment #1 |
11/07/2019
| Implemented |
6400.181(e)(12) | Individual #1's assessment did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 11/7/19 - This pending citation was reviewed as part of the ODP Licensing closing. Was prompted to send any information to the licensor regarding this citation as the assessment included "Recommendations for specific areas of training, programming and services." The corresponding regulation numbers were included on the SNAP assessment to further emphasis compliance to this regulation as well as the recommendations for this consumer. The assessment was then emailed to the ODP licensor and the consumers AE on 11/7/19 to verify the assessment met the regulation.
All other SNAP assessments were reviewed to confirm this requirement is addressed on the assessment and found to be in compliance.
The Executive Director will ensure the ODP licensor is properly oriented to the contents of this document ongoing.
The SNAP assessment will be closely monitored by the Program Specialist to ensure all aspects of the SNAP Assessment are updated per regulation and discussed during annual ISP meeting. See Attachment #1 |
11/07/2019
| Implemented |
6400.181(f) | The program specialist did not provide the assessment for individual#1 to the team members 30 days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 11/7/19 -Was prompted to send any information to the licensor regarding this citation. A copy of the annual ISP invitation letter was then emailed to the ODP licensor and the consumers AE to verify we could not meet the regulation since Consumer #1 was not in our care at the time of the annual ISP
The annual ISP was held on 5/9/2019 at Wernersville State Hospital. The Supports Coordinator sent out the invitation to the annual meeting on 4/5/2019. Consumer #1 was not admitted to our services until 6/6/2019. The Program Specialist completed the initial assessment within the 45 days of admission (6/30/2019).
All other consumers' assessments were confirmed to have been sent to the corresponding teams at least 30 days in advance.-
The Program Specialist will enter annual ISP dates in Outlook Calendar as a reminder and to ensure compliance moving forward. Plan in place starting 1/1/20. See Attachment #5 |
11/07/2019
| Implemented |
Article X.1007 | Alvarium is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #1,2,3 and 4 did not have a declination of living in Pennsylvania for the past 2 consecutive years in their file, and no FBI criminal history was completed. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Alvarium started new process and implemented new form on September 10, 2019. The HR recruiters will have the attestation form signed by new hires prior to first day of employment. There is also a question on the application if they have lived in their current state for the past two years.
Alvarium new hire, Victor Lwekamwa's paperwork is attached. He was hired 11/11/2019. Includes application page with question and the attestation. See Attachment #6
Also see attached completed FBI clearance for Staff #3. See Attachment #7 |
09/10/2019
| Implemented |