Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(3) | Individual #1's physical examination, completed 4/2/20 did not include immunization records. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The Director has notified Individual #1 previous PCP to obtain immunization record. The PCP is mailing the copy of immunization record to Individual #1 residence and staff will place in Individual #1 file. Going forward Director will create an admission packet checklist to make sure that all necessary documents including immunization record is on file at time of admission. [A copy of the immunization record for Individual #1 was provided to the Department on 1/11/21. Upon completion, the CEO or designee educated in the requirements of Individual's physical examinations shall audit individuals' physical examinations to ensure all required information is completed and all health services are arranged and provided as ordered. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |
6400.141(c)(11) | Individual #1's physical examination, completed 4/2/20 indicated to see medication list. The medication list was not attached. | 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. | Program specialist has made an appointment via tele-medicine for Feb 4, 2020 for Individual #1 physician to review medication regimen. Going forward Program Specialist will create a tracking sheet to remind staff during appointments to review the need of medications and if there is a need for blood work to obtain prescription for lab work. [Individual #1 had a Health maintenance medication list with PCP office on 1/11/21. A copy of the report had medications listed for Individual #1. A copy was provided to the Department on 1/11/21. Upon completion, the CEO or designee educated in the requirements of Individual's physical examinations shall audit individuals' physical examinations to ensure all required information is completed and all health services are arranged and provided as ordered. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |
6400.181(e)(1) | Individual #1's assessment completed 1/8/2020 did not include strengths, needs, preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Functional strengths needs and preference was added to Individual #1 assessment. The program specialist will review Chapter 6400 regulations again regarding assessments to ensure that all required information is included in the assessment. The Director/CEO will aid the program specialist in producing the proper documentation for the previous and future months, along with obtaining the necessary tools and knowledge to be more effective program specialist overall. [Individual #1's assessment was updated to include the functional strengths and needs, a copy was provided to the Department on 1/11/21. Immediately, the program specialist and CEO shall audit the current assessment documentation to ensure all required information is included so completion of all individual's assessment are completed with all required information. Immediately and at least quarterly for 1 year and continuing at least annually, the Program Specialist shall audit all Individual's current assessments to ensure all the required information is included, accurate and up to date. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
01/04/2021
| Implemented |
6400.181(e)(2) | Individual #1's assessment, completed 1/8/2020 did not include dislikes and interests of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Dislikes and interest was added to Individual #1 assessment. The program specialist will review Chapter 6400 regulations again regarding assessments to ensure that all required information is included in the assessment. The Director/CEO will aid the program specialist in producing the proper documentation for the previous and future months, along with obtaining the necessary tools and knowledge to be more effective program specialist overall [Individual #1's assessment was updated to include dislikes and interests of the individual, a copy was provided to the Department on 1/11/21. Immediately, the program specialist and CEO shall audit the current assessment documentation to ensure all required information is included so completion of all individual's assessment are completed with all required information. Immediately and at least quarterly for 1 year and continuing at least annually, the Program Specialist shall audit all Individual's current assessments to ensure all the required information is included, accurate and up to date. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
01/04/2021
| Implemented |
6400.181(e)(14) | Individual #1's assessment, completed 1/8/2020 did not include the individual's ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The ability to swim was added to Individual #1 assessment. The program specialist will review Chapter 6400 regulations again regarding assessments to ensure that all required information is included in the assessment. The Director/CEO will aid the program specialist in producing the proper documentation for the previous and future months, along with obtaining the necessary tools and knowledge to be more effective program specialist overall. [Individual #1's assessment was updated to include that s/he is unable to swim, a copy was provided to the Department on 1/11/21. Immediately, the program specialist and CEO shall audit the current assessment documentation to ensure all required information is included so completion of all individual's assessment are completed with all required information. Immediately and at least quarterly for 1 year and continuing at least annually, the Program Specialist shall audit all Individual's current assessments to ensure all the required information is included, accurate and up to date. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
01/04/2021
| Implemented |
6400.15(b) | The agency did not complete a self-assessment on the Department licensing inspection instrument for community homes. The agency used a programmatic self-assessment document. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The Director has completed the self assessment of the home on Dec 30, 2020. Annually thereafter the Director or an appointed representative will complete the assessment 3-6 months prior to expiration of the Certificate of Compliance. [Self-assessment, dated 12/15-17/21, completed on the Department licensing instrument was submitted to the Department on 1/11/21. Upon completion, the CEO or designee shall audit the self-assessment to ensure full and accurate completion on the most recent Department licensing inspection instrument. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 1/14/2021)] |
12/31/2020
| Implemented |
6400.34(a) | Individual # 1 was informed and explained individual rights on 9/1/20. The rights document did not include: 6400.32(a) An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; 6400.32(b) An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion; 6400.32(c) An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment; 6400.32(d) An individual shall be treated with dignity and respect, 6400.32(e) An individual has the right to make choices and accept risks; 6400.32(f) An individual has the right to refuse to participate in activities and services; 6400.32(g) An individual has the right to control the individual's own schedule and activities; 6400.32(h) An individual has the right to privacy of person and possessions; 6400.32(i) An individual has the right of access to and security of the individual's possessions; 6400.32(j) An individual has the right to voice concerns about the services the individual receives; 6400.32(k) An individual has the right to participate in the development and implementation of the individual plan; 6400.32(l) an individual has the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses; 6400.32(m) an individual has the right to unrestricted access to send and receive mail and other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses; 6400.32(n) unrestricted and private access to telecommunications; 6400.32(o) An individual has the right to manage and access the individual's finances; 6400.32(p) choose with whom to share a bedroom; 6400.32(q) to furnish and decorate the individuals bedroom and common areas of the home; 6400.32(r) to lock the individuals bedroom door; 6400.32(s) to an entry mechanism to lock and unlock the entrance to the home, and 6400.32(t) access to food at any time; 6400.32(u) An individual has the right to make health care decisions; 6400.32(v) An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual Rights was updated and signed by Individual #1 on 12/31/2020. Going forward each individual admitted will have the individual rights in his/her admission packet to review and sign upon admission and annually thereafter. [Individual Rights document was updated to include all individual rights per 6400 regulations and was signed by Individual #1 on 1/21/21, copy provided to the Department on 1/21/21 Upon admission and annually, the CEO or designee shall review all individual rights documentation to ensure the full individual rights and the process to report rights violations are informed and explained to all individuals. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/21/21)] |
12/31/2020
| Implemented |
6400.46(d) | Direct Service Worker #1 did not have current training in first aid. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Direct Care Worker #1 scheduled First Aid training for 1/16/2020. The Supervisor will ensure that all staff has required training upon initial hire as well as within the time frames required by the 6400 regulations. The program specialist will develop an audit tool to track staff training including first aid required within 30 days of receipt of this plan of correction. [Direct Service Worker #1 completed first aid training completed on 1/20/21, documentation of the training certificate was provided to the Department on 1/21/21. Immediately, the CEO or designee shall develop and implement a staff training tracking system to include a notification, scheduling, review and tracking document to ensure all staff persons are trained as required and documentation is maintained as required. At least quarterly, the CEO or designee shall audit the training tracking document to ensure it is up-to-date and staff are trained as required. (DPOC by AES,HSLS)] |
12/31/2020
| Implemented |
6400.50(a) | The fire safety training records for Program Specialist #1, Direct Service Worker #2 and Chief Executive Officer #3 did not include the training source, content, dates, and length of the training. | 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. | A fire safety inspection conducted by a fire safety expert has been scheduled with ABC Fire Solutions. The Director or designee will be responsible for maintaining documentation of these actions. 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. [CEO #3 completed Plan to Get out Alive fire safety on 1/5/21 for 2 hours, certificate submitted to the Department on 1/11/2021. Program Specialist #3 completed Plan to Get out Alive fire safety on 1/5/21 for 2 hours, certificate submitted to the Department on 1/20/2021 . Direct Service worker #2 completed Plan to Get out Alive fire safety on 1/5/21 for 2 hours, certificate submitted to the Department on 1/20/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/20/21)] |
12/31/2020
| Implemented |
6400.52(c)(1) | Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships and kept in program specialist and CEO file. [CEO #3 completed Person Centered Practice training on 1/10/2021. Program Specialist #1 completed Person Centered Practice training on 1/8/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |
6400.52(c)(2) | Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Services Law, the Adult Protective Services Act, and applicable protective services regulations. Chief Executive Officer #3, date of hire 9/15/2018, annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Services Law, the Adult Protective Services Act, and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The Director has created a tool for annual trainings specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction The annual training hours will be specified of prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act and the child protective services law. The training will be kept in the CEO and Program Specialist employee file. [CEO #3 completed Abuse Detection, reporting and prevention of abuse suspected abuse and alleged abuse on 1/10/2021. Program Specialist #1 completed Abuse Detection, reporting and prevention of abuse suspected abuse and alleged abuse on 1/7/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |
6400.52(c)(3) | Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass individual rights. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of Individual Rights. The training will be kept in CEO and Program Specialist employee file. [CEO #3 completed Individual rights training on 1/7/2021. Program Specialist #1 completed Individual rights training on 1/7/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |
6400.52(c)(4) | Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass recognizing and reporting incidents. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of Reporting Incidents all trainings will be kept in employee file[CEO #3 completed Individual rights training on 1/7/2021. Program Specialist #1 completed Individual rights training on 1/7/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |
6400.52(c)(5) | Program Specialist #1's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the safe and appropriate use of behavior supports if the person works directly with an individual. Chief Executive Officer #3's annual training hours for training year June 1, 2019 through May 31, 2020 did not encompass the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | The Director has created a tool for annual training specific for Program Specialist and CEO that will be completed within 30 days of this plan of correction. The annual training hours will be specified of safe and appropriate use of behavior supports if the person works directly with an individual. All training will be kept in employee file. [CEO #3 completed DDx: Functional Behavioral Assessment and Behavior Support Planning training on 1/10/2021. Program Specialist #1 completed DDx: Functional Behavioral Assessment and Behavior Support Planning training on 1/8/2021. At least quarterly for 1 year, the CEO and Program Specialist shall audit all training records for all employees to ensure all staff persons including the CEO and Program specialist complete training in all required areas, upon hire and annually as required and documentation of all trainings is maintained. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |
6400.166(a)(13) | Individual #1's December 2020 medication administration record did not include the signature and initials for Direct Service Worker #2 who administered medications to Individual #1 on 12/2/2020, 12/5/2020, and 12/6/2020 at 8:00AM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The Director who is a DPW certified medication administration train the trainer and observer has retrained staff on medication administration. Direct care worker #2 passed the medication administration training on 12/31/2020. The Director will ensure that all future medication administration trainings are performed by a certified DPW medication administration trainer whose certifications are current. [The January 2021 medication record for Individual #1 recorded all medication administrations form January 1 to January 11, 20212. (copy submitted to the Department on 1/11/21). At least monthly and immediately following any medication changes, a designated staff person who is qualified to administer medications shall audit the current medication administration record the medications and physicians' orders for the individual(s) to ensure individual(s) are administered medication as prescribed and documented as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/20) |
12/31/2020
| Implemented |
6400.166(b) | Calcium 500mg, Carbamazepine SUS 100/5ml, Ferrous Sulfate 325mg prescribed to Individual #1 were not documented as administered at 8:00AM on 12/16/2020. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Director who is a DPW certified medication administration train the trainer and observer has retrained staff on medication administration. Direct care worker #2 passed the medication administration training on 1/4/2021. The Director will ensure that all future medication administration training are performed by a certified DPW medication administration trainer whose certifications are current.[The January 2021 medication record for Individual #1 recorded all medication administrations form January 1 to January 11, 20212. (copy submitted to the Department on 1/11/21). At least monthly and immediately following any medication changes, a designated staff person who is qualified to administer medications shall audit the current medication administration record the medications and physicians' orders for the individual(s) to ensure individual(s) are administered medication as prescribed and documented as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/20) |
01/04/2021
| Implemented |
6400.213(1)(i) | Individual #1's record did not include eye color, hair color, primary language, and religious affiliation. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Updated face sheet was placed in Individual #1 file with all pertinent information including eye and hair color, religion and primary language. Going forward a face sheet will be placed in each admission packet to be filled out in it's entirety and placed in individuals medical record. [A copy of the updated "face sheet" for Individual #1 to include eye color, hair color, primary language, and religious affiliation was provided to the Department on 1/11/21. At least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure all required information is included as per 6400.213(1)-(8). Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/14/21)] |
12/31/2020
| Implemented |