Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The agency did not complete a self-assessment of this home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| All new site supervisors and residential program manager will be trained on Self-Assessments and completion of Self-Assessment tool as it relates to regulation 6400.15a,b,and c. This training will be completed by October 12, 2021. The training record will be maintained in the employee personnel file.
As per regulation 6400.15a a Self-Assessment tool will be completed for this service location 3-6 months following this licensing review and 3 to 6 months prior to the end of the current licensing agreement date. These are to be completed by December 15, 2021 and the second to be completed by April 15, 2022. and annually there after. |
10/15/2021
| Implemented |
6400.141(c)(14) | Individual #1's physical examination, completed 10/23/2020, does not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's annual physical was on 10/4/21 and his social medical history was attached to his appointment form and reviewed by the physician. |
10/04/2021
| Implemented |
6400.52(c)(2) | Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include 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 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 CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions.
Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. The IDD Director will complete this training by 10/15/21 and according to the Training calendar there after. All training records will be kept in her personnel file in the departments office for review. |
10/15/2021
| Implemented |
6400.52(c)(3) | Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions.
Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. |
10/15/2021
| Implemented |
6400.52(c)(4) | Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021 did not include recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions.
Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. |
10/15/2021
| Implemented |
6400.52(c)(5) | Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include 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 CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR.
The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions.
Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. |
10/15/2021
| Implemented |
6400.52(c)(6) | Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include implementation of the individual plan if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions.
Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. |
10/15/2021
| Implemented |