Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245139 Renewal 06/10/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(11)The annual assessments for individual #1 (dated 5/3/24), individual #2 (dated 5/3/24), individual #3 (dated 12/1/23), and individual #4 (dated 10/25/23) do not address whether or not the individuals' had a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable.The Program Specialist wrote an addendum to the current assessment for Individual # 1 on 6/11/2024 to include information related to the psychological evaluation, please see attachment # 1. The Program Specialist wrote an addendum to the current assessment for Individual # 2on 6/12/2024 to include information related to the psychological evaluation, please see attachment # 2. The Program Specialist wrote an addendum to the current assessment for Individual # 3 on 6/11/2024 to include information related to the psychological evaluation, please see attachment # 3. The Program Specialist wrote an addendum to the current assessment for Individual # 4 on 6/11/2024 to include information related to the psychological evaluation, please see attachment # 4. All Program Specialists were trained on regulation 2380.181(e)(11) by the Director of Quality Assurance on 6/13/2024 and 6/14/2024, Please see Attachment # 5. The Director of Quality Assurance met with the Program Specialists on 6/13/2024 and 6/14/2024, the meeting was to inform the Program Specialists to review all files to ensure that the Psychological Evaluation section was present and to do an addendum to the Assessments that were missing that section. The Program Specialist will have this completed by 6/30/24. All assessments will be provided to the Director of Quality Assurance to ensure that the assessments were reviewed and updated. Once all assessments have been verified they will be filed, this will occur no later than 7/01/2024. 07/01/2024 Implemented
2380.21(u)Individual #3 was last informed of their individual rights on 9/27/21.The facility 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 facility and annually thereafter.The Program Specialist reviewed with individual #3 their new releases that include the individual rights and the process to report a rights violation on 6/12/2024, please see attachment # 6. Program Specialist was trained on regulation 2380.21(u) by the Director of Quality Assurance on 6/14/2024, Please see Attachment # 7. The Director of Quality Assurance met with the Program Specialist on 6/14/2024, the meeting was to inform the Program Specialist to review all files to ensure that the correct releases were signed by all individuals and are current. The Program Specialist will have this completed by 6/30/24. All releases will be provided to the Director of Quality Assurance to ensure that the releases are the correct releases and that they were reviewed and current. Once all releases have been verified they will be filed, this will occur no later than 7/01/2024. 07/01/2024 Implemented
SIN-00225999 Renewal 06/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)At the time of inspection, there was a golf ball size amount of lint accumulated in the lint trap of the laundry dryer. Corrected on site.Floors, walls, ceilings and other surfaces shall be free of hazards.The sign that was once on the dryer notifying staff to remove lint from the dryer was removed therefore lint wasn't removed from the recent usage of the dryer. The lint trap was cleaned on 6/28/2023. A sign was made and placed back on the dryer for all staff to see. Picture was taken to show compliance. Please see Attachment #1. 07/07/2023 Implemented
2380.181(e)(7)Individual #1 01/20/23 Annual Assessment does not state if Individual #1 is able to move away quickly from a heat source.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The program specialist didn't have the correct wording for compliance. The program specialist updated the section of the assessment pertaining to knowledge of the dangers of heat sources as an addendum on 6/28/2023. Attachment #3 07/05/2023 Implemented
SIN-00208680 Renewal 07/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)No vision/hearing screening was provided for Individual #3.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #3's PCP's office faxed the computer printout from their annual physical that was held on 12/22/2021, it shows that their eyes and ears were evaluated but doesn't clearly state that they had screenings as Attachment #1. A completed physical for Individual #3 that shows where the vision and hearing was completed at the physical exam as Attachment #2 08/05/2022 Implemented
2380.111(c)(7)Individual #2's most recent physical completed on 9/29/21 does not address health maintenance needs, blood work, or medication regiment. This section of the physical is blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Individual #2's physical was faxed back to the PCP's office requesting this section to be completed. It was completed on 7/27/2022 and faxed back to the agency on 7/28/2022 as Attachment #7. 08/05/2022 Implemented
2380.111(c)(10)Individual #2's most recent physical completed on 9/29/21 does not address information pertinent to diagnosis/treat in the event of an emergency. This section is blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #2's physical was faxed back to the PCP's office requesting this section to be completed. It was completed on 7/27/2022 and faxed back to the agency on 7/28/2022 as Attachment #7. 08/05/2022 Implemented
2380.111(c)(11)111d (NOT IN CLS): Individual #1's most recent TB test completed on 10/21/21 was not signed and dated by an RN/LPN/MD/CNP/PA-C. It was completed by a Medical Assistant. Individual #2's TB test that was provided only has one date of 9/15/20 wrote on the document for "date read". No other information is on the form including the date administered, who administered it, who read it. In addition, there is no date or signature on the document.Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Communicated with Individual #1's PCP's office in regards to the finding from licensing requesting for verification that Individual #1's TB screening was reviewed/overseen by either an RN/LPN/MD/CNP/PA-C. I was able to speak with the Nurse that oversaw the results, the nurse was signing off on the results and faxed them as Attachment #10. Individual #2's physical was faxed back to the PCP's office requesting this section to be completed. It was completed on 7/27/2022 and faxed back to the agency on 7/28/2022 as Attachment #7. 08/05/2022 Implemented
2380.181(a)-Individual #1 was admitted to day program on 8/23/21. The initial assessment was not completed until 10/25/21; outside of the 60-day timeframe. Individual #2 was admitted to day program on 3/17/22. The initial assessment was not completed until 5/19/22; which is outside of the 60-day window.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.A completed initial assessment for Individual #4 was provided as Attachment #12 and face sheet with admission date as Attachment #13 showing an assessment that was completed within 60 days. 08/05/2022 Implemented
2380.36(a)Staff #3 began working with individuals on 8/25/21. The first documented fire safety training is not until 7/21/22.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.Orientation for the most recent hire in the 2380 CPS facility as Attachment #15a and copy of completed fire safety training as Attachment #15b, showing where staff are receiving fire safety training at orientation prior to working in the program areas with clients. 08/05/2022 Implemented
2380.36(b)No documentation was provided verifying that Staff #2 had fire safety training.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff #2 received fire safety training on 7/25/2022, as attachment #17. Training showing where 2 of the original staff hired prior to opening the facility in August 2021 received their annual fire safety training as Attachment #18a & 18b. Other staff listed from the 2021 fire safety training log are no longer with CCCC. 08/30/2022 Implemented
SIN-00176456 Renewal 09/15/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.82REPEAT VIOLATION from annual inspection held on 5/2/19: The emergency exit located in the sensory room was unable to be opened fully; allowing exit if need be. The bottom of the door was catching on the concrete outside.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.The Emergency exit in the Sensory room was fixed on 9/18/20, a picture of the door completely open to the outside was taken and is sent in as Attachment #51. The completed work order showing the exit was fixed is sent in as Attachment #52. The Sensory room doors were added to the Monthly Egress Tracking Chart; the doors will be checked monthly with all other egress checks. The chart will be completed no later than 10/19/2020, a copy of the completed check of the agency egress will be sent in as Attachment #53. 10/19/2020 Implemented
2380.87(b)Program Area four was not equipped with a working device on the exterior wall close to the downstairs lobby to alert individuals with hearing impairments of a fire. If individual #9 were sitting in Program Area 4 facing that wall, they would not be alerted to a fire.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.A new fire alarm strobe was installed on 9/21/2020, pictures of the wall where the strobe was added in Program Area 4 is sent in as Attachment #46 and #47. The strobe was checked as operating on 9/22/2020, copy of the fire drill log to show it was checked is sent in as Attachment #48. The completed work order (once received) as Attachment #50 and email involved with the strobe installation is being sent in as Attachments #49. 09/21/2020 Implemented
2380.111(a)Individual #7 received a physical examination on 2/6/19 and not again until 2/26/2020, outside the annual time frame requirement. There was no evidence that the individual was out of program during the time her physical examination lapsed.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Sending in Individual MB copies of annual physical exam where it was completed within the required timeframe, sent as Attachment #59. Program Specialist will be retrained on the Procedures for maintaining up to date annual physical documentation and other required medical documentation no later than 10/19/2020, a signature sheet along with the contents of the training will be sent in as Attachment #45. 10/19/2020 Implemented
2380.111(c)(5)REPEAT from 5/2/19 annual inspection: Individual #7's 2/26/2020 physical examination record does not include the results of her recent Tuberculin skin test or previous chest x-ray. The record included a date of what appeared to be "1/20/20" in the field for a chest x-ray. However, the results were not noted and the same field stated a chest x-ray was not applicable. Her last recorded Tuberculin skin test with negative results was completed on 5/2/18.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Individual #7 received her Tuberculin skin test on 9/22/2020, it was read on 9/24/2020 with negative results, sending in as attachment #43. Sending in Individual copies of TB screening where it was completed within the required timeframe, sent as Attachment #44. Program Specialist will be retrained on the Procedures for maintaining up to date annual physical documentation and other required medical documentation no later than 10/19/2020, a signature sheet along with the contents of the training will be sent in as Attachment #45. 10/19/2020 Implemented
2380.111(c)(6)Individual #8's physical does not address whether or not he is free and clear of communicable diseases.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.Individual #8¿s annual physical was updated and faxed back on 9/17/2020 by the physician to include that the individual was free from communicable disease. Sending in as Attachment #42. A checklist will be developed to help reviewing Program Specialists review incoming annual physical forms and all Program Specialist will be trained on the checklist no later than 10/30/2020. The signature sheet of the training will be sent in as Attachment #39 once completed. A completed checklist will be sent in by next annual physical that is completed, it will be sent in as Attachment #40. 10/30/2020 Implemented
2380.111(c)(8)Individual #8's physical does not address whether or not he has limitations.The physical examination shall include: Physical limitations of the individual.Individual #8¿s annual physical was updated and faxed back on 9/17/2020 by the physician to include whether physical limitations are required. Sending in as Attachment #42. A checklist will be developed to help reviewing Program Specialists review incoming annual physical forms and all Program Specialist will be trained on the checklist no later than 10/30/2020. The signature sheet of the training will be sent in as Attachment #39 once completed. A completed checklist will be sent in by next annual physical that is completed, it will be sent in as Attachment #40. 10/30/2020 Implemented
2380.111(c)(9)Individual #3's 12/30/19 physical examination record did not explain which animals he was allergic to. His record stated that he was allergic to "some animals" but did not provide further clarification.The physical examination shall include: Allergies or contraindicated medication.Individual #3¿s annual physical was updated on 9/21/2020 by the physician to clarify what ¿some animals¿ meant, his allergy pertains to dogs and cats. Sending in as Attachment #41. A checklist will be developed to help reviewing Program Specialists review incoming annual physical forms and all Program Specialist will be trained on the checklist no later than 10/30/2020. The signature sheet of the training will be sent in as Attachment #39 once completed. A completed checklist will be sent in by next annual physical that is completed, it will be sent in as Attachment #40. 10/30/2020 Implemented
2380.111(c)(10)On Individual #1's annual physical, under the information needed in case of an emergency it states to contact family. Individual #6's physical indicated that he had no medical information that would be pertinent to relay to emergency personnel in the event of an emergency. Individual#7's 2/26/2020 physical examination record does not include information pertinent to diagnosis and treatment in case of an emergency. The field only stated to "contact next of kin emergency contact."The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Information was prepopulated for the ¿Medical Information Pertinent to Diagnosis and Treatment in Case of an Emergency¿ to be attached to Individual # 1¿s annual physical and sent to the physician. The physician made corrections and added information and signed on 9/28/2020. This information was provided to the Life Sharing Specialist to be prepopulated for her next annual physical exam. The information signed by the physician is being sent in as Attachment #36. Information was prepopulated for the ¿Medical Information Pertinent to Diagnosis and Treatment in Case of an Emergency¿ to be attached to Individual # 6¿s annual physical and sent to the physician. The physician signed on 9/22/2020. The information signed by the physician is being sent in as Attachment #37. This information will be prepopulated for his next annual physical exam. Information was prepopulated for the ¿Medical Information Pertinent to Diagnosis and Treatment in Case of an Emergency¿ to be attached to Individual # 7¿s annual physical and sent to the physician. The physician signed on 9/30/2020. The information signed by the physician is being sent in as Attachment #38. This information will be prepopulated for her next annual physical exam. A checklist will be developed to help reviewing Program Specialists review incoming annual physical forms and all Program Specialist will be trained on the checklist no later than 10/30/2020. The signature sheet of the training will be sent in as Attachment #39 once completed. A completed checklist will be sent in by next annual physical that is completed, it will be sent in as Attachment #40. 10/30/2020 Implemented
2380.115(1)The Emergency Medical Plan does not indicate a specific hospital or source of health care that will be used in case of an emergency that is dictated by the individuals preference or need, it states "Hospital closest to the emergency" or "preferred hospital". The plan was not developed to address each individual's unique preference.The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency.The Emergency Medical plan was updated on 9/28/2020 and is being sent in as Attachment #33. Also face sheets for individuals are also being sent in as Attachments #34 and #35 to show individual¿s hospital preferences. Information in regards specifically to preferred hospital will be gathered during intake meeting and added to the face sheets moving forward. 09/28/2020 Implemented
2380.173(1)(iv)Each individual record should address the religious affiliation. Individual #2 and Individual #6's record states "none known" for religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Updated face sheets to include religious affiliations of Individual #2, and Individual #6. A copy of their face sheet is being sent in as the following attachments: Individual #2 as Attachment #30, and Individual #6 as Attachment #31. Program Specialists will be retrained on regulation 2380.173 (1) (iv) no later than 10/19/2020, signature sheet of the training will be sent as Attachment #32. 10/19/2020 Implemented
2380.173(1)(v)Each individual record should have current dated photograph in file. As per regulations, photo should be updated annually. Individual # 1 last had a photo taken on 7/5/18. Individual #3 last had his photograph taken on 12/27/16. Individual #7 last had a photograph taken on 7/20/15. Individual #8 last had his photo updated on 6/11/18.Each individual's record must include the following information: Personal information including: A current, dated photograph.Updated pictures were taken of Individual #1, Individual #3, Individual # 7, and Individual #8. A copy of their photo pages along with date taken is being sent in as the following attachments: Individual #1 as Attachment #25, Individual #3 as Attachment #26, Individual #7 as Attachment # 27, and Individual #8 as Attachment #28. Program Specialists will be retrained on regulation 2380.173 (1) (v) no later than 10/19/2020, signature sheet of the training will be sent as Attachment #29. 10/19/2020 Implemented
2380.181(e)(8)Individual #3's 12/31/19 assessment did not include an assessment of what his ability to evacuate the day program facility is. His assessment states how he evacuates his family's home and what his family believes he would need for evacuation.The assessment must include the following information: The individual's ability to evacuate in the event of a fire.Individual #3¿s assessment was updated on 9/17/2020 to include his ability to evacuate incase of an emergency. The updated assessment along with signatures and cover letter is sent in as Attachment #22. Program Specialist will be retrained on regulation 2380.181 (e) (8) no later than 10/19/2020, signature sheet of the training will be sent as Attachment #24. 10/19/2020 Implemented
2380.181(e)(10)Individual #2 has four allergies listed on face sheet and medical records. On her assessment, only three of the four allergies are listed: Wheat, Amoxicillin, and NSAIDS. She is also allergic to diphenhydramine; which is absent from her assessment. Individual #3's 12/31/19 assessment did not include his allergy to "some animals" that was recorded on his physical examination record.The assessment must include the following information: A lifetime medical history.Individual #2¿s assessment was updated on 9/17/2020 to include all allergies. The updated assessment along with signatures and cover letter is sent in as Attachment #21. Individual #3¿s assessment was updated on 9/17/2020 to include allergies related to animals (dogs and cats) that was updated on his annual physical on 9/21/2020 (Attachment #41). The updated assessment along with signatures and cover letter is sent in as Attachment #22. Program Specialists will be retrained on regulation 2380.181 (e) (10) no later than 10/19/2020, signature sheet of the training will be sent as Attachment #23. 10/19/2020 Implemented
2380.21(u)Individual #3 last had his rights reviewed in 2015. This is outside the annual time frame. Individual #3's mother is his Power of attorney and she has not been informed of his rights or the process to report a rights violation. Individual#5 entered the program on 10/7/2019. At the time of the 9/15/2020 inspection he nor his sister, his legal guardian, had the individual's rights or the process of reporting a rights violation reviewed with them. Individual #7 had her rights reviewed in 2007. She has not been informed of her rights and the process to report a rights violation since that; outside of the annual time frame. Individual #8 had his rights reviewed on 5/21/18. He has not had his rights reviewed since that date; outside of the annual time frame. Additionally, the department issued updated individual's regulatory rights effective 2/3/2020. At the time of the 9/15/2020 inspection, Individuals #1, #2, #4, #6, and #8 were not informed of the updated rights or the process to report a rights violationThe facility 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 facility and annually thereafter.The individual rights and the process to report rights violations were reviewed with Individual #1, Individual #2, Individual #3 (and POA), Individual #4, Individual #5, Individual #6, Individual # 7, and Individual #8. A copy of the rights is being sent in as Attachment #9. The signature sheets are being sent in as the following attachments: Individual #1 as Attachment #10, Individual #2 as Attachment #11, Individual #3 and POA as Attachment # 12, Individual #4 as Attachment #13, Individual #5 as Attachment #14, cover letter showing that the individual rights were sent the Individual¿s guardian on 9/21/2020 (have not received signed signature sheet from guardian) as Attachment #15, Individual #6 as Attachment#16, Individual #7 as Attachment #17 and Individual #8 has not returned his signature sheet, once received it will be sent as Attachment #18. A copy of the send out letter to Individual #8 and family is being sent as Attachment #58. Program Specialists will be trained on regulation 2380.21(u) no later than 10/19/2020 and will be sent in as Attachment #19. Individual rights and the process to report rights violations were added to the individual¿s annual releases and will be reviewed annually. 10/19/2020 Implemented
2380.126(a)(11)Individual #5's mars from October 2019-March 2020 did not include the diagnosis or purpose for his Topiramate, Clonazepam or Diazepam. Individual #6's medication administration records (mars) from July 2019-March 2020 did not include the diagnosis or purpose for his Clonidine medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #5¿s MAR that is being used in his home by CPS staff during COVID-19 does have the diagnoses listed with each medication, sending a copy of a completed MAR for August 2020 as Attachment #56. Individual #6 MAR was updated for October 2020 to include the diagnosis for the medication, this is being sent at Attachment #57. A meeting will be scheduled with Medication Administration Trainers to updating MARs to meet all regulatory standards, this meeting will occur prior to the Facility re-opening. A copy of the meeting¿s signature sheet will be sent as Attachment #55. 10/30/2020 Implemented
2380.129(a)Staff #4 began Medication Administration Training prior to the pandemic. Two observations were completed in March 2020. The training was not completed when the pandemic hit. On, March 21, 2020, the Department issued Appendix K modifying medication administration training requirements. One of the requirements was that staff are to be trained on the Agency's Medication Administration Record and Documentation. As of 9/16/20, this has not occurred. Staff #4 is administering medications.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).Staff #4 was trained by a Medication Administration Trainer on 9/30/2020 on Medication Administration Record and Documentation, sending in as Attachment # 54. A meeting will be scheduled with Medication Administration Trainers to discuss training measuring during COVID-19, this meeting will occur prior to the Facility re-opening. A copy of the meeting¿s signature sheet will be sent as Attachment #55. 10/30/2020 Implemented
2380.181(f)There is no evidence that Individual #7's 4/3/2020 assessment was sent to any team members. Her team consisted of herself, her supports coordinator, her family she lives with, and day program.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The Program Specialist sent the assessment to Individual #7¿s family on 9/16/2020. The cover letter showing that the assessment was sent on 9/16/2020 as Attachment #6. Program Specialist will be retrained on regulation 2380.181(f) no later than 10/19/2020, signature sheet of the training will be sent as Attachment #7. A cover letter, assessment signature sheet and meeting signature sheet for individuals will show where an assessment was completed and sent at least 30 days prior to the meeting as Attachment #8. 10/19/2020 Implemented
2380.186Individual #5's individual plan states he has a seizure protocol for staff to implement while he is attending program. According to his seizure protocol, staff pass his Vegas Nerve Stimulator (VNS) magnet over the pulse generator on the left side of the individual's chest at the onset of his seizure. Staff then are to continue to swipe the VNS magnet over the same location every minute, for 5 total minutes in attempts to stop his seizure. There is no evidence that staff swiped his VNS magnet over his pulse generator at the onset of any of the following documented seizures, or that they continued to swipe the magnet every minute for seizures lasting long enough to continue to swipe the magnet. Staff documented that he had a 30 second seizure on 11/26/19, 20 min seizure on 11/18/19, 2 separate 3 second seizures on 11/13/19, 30 second seizure on 12/3/19, 3 minute seizure on 12/31/19, 1/2/2020 he had a 5 minute seizure and "magnet" was logged as used but didn't indicate how many times they used the magnet to comply with his protocol, and an undocumented length of time for seizure on 2/25/2020 and staff reported he dropped his head, stopped breathing for 20 seconds multiple times, had trouble breathing, 30 seconds on seizure and 30 seconds off continuous then was taken by ambulance to the hospital at 2:03. Individual #5's seizure protocol also states that if his head drops during a seizure and is having obvious difficulty breathing, staff will lift his head, extend his cervical spine backwards to open airway, if able to do so safely. The following are documented seizures where staff indicated the individual's head dropped and/or he had difficulty breathing and there was no evidence that staff attempted to lift his head to open his airways: dropped his head and was unresponsive for 30 seconds on 11/26/19, 2 separate 3 second seizures on 11/13/19 where he was gasping for air, 12/3/19 30 second seizure where his head dropped, 3 minute seizure on 12/31/19 where he dropped his head and had labored deep breathing, and an undocumented length of time for seizure on 2/25/2020 and staff reported he dropped his head, stopped breathing for 20 seconds multiple times, had trouble breathing, 30 seconds on seizure and 30 seconds off continuous then was taken by ambulance to the hospital at 2:03PM.The facility shall implement the individual plan, including revisions.A meeting is scheduled for individual # 5 for 10/8/2020 by both the residential provider and day program to develop a new seizure tracking chart that will be universally used by all parties. Signature sheet along with meeting minutes will be sent in as Attachment #1. The new tracking chart will include all interventions from the Seizure monitoring plan based off the physician¿s recommendations. The new tracking chart will also include start and end times for the seizure. The new tracking chart will be sent in once staff are trained and start using the chart to track seizures as Attachment #2. Once chart is developed all person¿s involved in individual #5¿s care will be trained on the plan and new charting document and the training sheet will be sent in as Attachment #3. Program Specialist will be retrained on regulation 2380.186 no later than 10/19/2020, signature sheet of the training will be sent in as Attachment #4. Updates to the Seizure monitoring plan were completed on 9/28/2020 as Attachment #5. 10/30/2020 Implemented
SIN-00175039 Unannounced Monitoring 07/30/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.17(f)On 3/3/2020 Individual #1's psychiatrist suggested that she "only use her tablet downstairs, so it can be supervised and so that she doesn't take in the bathroom and her bedroom and not be tempted to get on it at night, then isn't sleeping. {Individual #1} agreed to try this." Her psychiatrist initiated this recommendation after being informed on 3/3/2020 of Individual #1's recent, inappropriate electronic behavior with a man from another state requiring involvement from the Department of Homeland Security. The 3/3/2020 appointment summary record stated a team meeting was set up for March 18th to discuss the situation. There is no evidence that a team meeting occurred on 3/18/2020, that discussions occurred with Individual #1 to follow the psychiatrist's recommendations, or any attempts to train the individual on appropriate internet usage to she does not end up being the victim or perpetrator of a crime via the internet. According to a 6/16/2020 monthly monitoring form, Staff person #1 recorded, "June 2nd a discussion was made about setting up a meeting that was needed before lockdown", and "June 16th finally had a team meeting regarding her inappropriate electronic tablet use. Some time after that meeting, {Individual #1} agreed to have her mom keep her tablet." Three months elapsed before the agency held a team meeting to discuss the psychiatrist's recommendations and concerns. There was no evidence to suggest that the facility took immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of the incident, alleged incident or suspected incident.The facility shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.8/24/2020- At the end of the work day on 3/16/2020, staff were told under direct orders from the Governor that the office was to close and no one was permitted on the premises until for notice. The 4C¿s is not set up for remote working at this time. When all team members from 4C¿s were able to return to the building, Staff #1 reached out to Individual #1¿s Supports Coordinator and Guardian about setting up a new meeting date. Guardian, due to work schedule and babysitting, was unable to meet until 6/15/2020. That is when Individual #1 agreed to give her electronic tablet to her mom. After Individual #1¿s psychiatric appointment on 3/3/2020, it was discussed with her by her Lifesharing Provider the importance of Internet Safety and following the recommendations of her psychiatrist. Attachment #1 shows that at Individual #1¿s next psychiatric appointment 2 weeks later that she only followed the recommendations for 2 days. At meeting on 6/15/2020 with team and Individual #1 it was also discussed that Individual #1 be set up with a Sexual Assessment. The Supports Coordinator was setting that up with FLP. The referral has been made and we are just waiting for them to get back to us with a date. The team met on 8/24/2020 to discuss what would be a safe plan for internet usage for Individual #1 if after she has the Assessment and would get her electronic tablet back, but if FLP would not make any recommendations. Team and Individual #1 agreed that the best plan for her safety would be that she will only access the internet/be on her electronic tablet in common areas of the house where others could provide supervision. Individual #1 also agreed that she will leave her devices downstairs when she went up to bed at 8pm. She will also leave the tablet at home when she goes to visit with others. The life sharing provider will document if Individual #1 is following the agreement. If she does not the team will seek out a restrictive plan through Behavioral Supports. On 8/21/2020 Individual #1 completed an Internet Safety training at home with her Community Participation staff. The training consisted of an interactive online training as well as a packet of handouts, see Attachments #2, 3, 4, 5, 6, 7, & 8. After Individual #1 completed the training she completed a summary of what she learned from the training. Her and her Community Participation staff both signed off once the training was completed, see Attachment #9. Lifesharing Specialist will complete monthly home visits as well as read over monthly documentation to make sure Individual #1 is being safe online. 08/24/2020 Implemented
2380.17(a)(8)On 2/24/2020, Department of Homeland Security investigators arrived at the facility to speak with Individual #1 due to her involvement over the internet with a man who was apprehended by law enforcement. Staff person #2 spoke with the investigators on 2/24/2020 about the investigation they were conducting. An incident report of the law enforcement activity at the program was never reported to The Department.The facility should report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Law Enforcement activity that occurs during the hours of facility operationStaff #2 was re trained on Incident Management Bulletin and proper reporting processes by Agency Incident Management Representative. Staff#2 will review incidents with Agency Incident Management Representative to ensure a clear understanding of how incidents are reported and filed. Attachement # 1is the training sheet for Staff # 2. 08/18/2020 Implemented
SIN-00167626 Unannounced Monitoring 11/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Underneath the kitchen sink in program area #3 contained unlocked poisonous materials. Green Earth foaming skin cleanser x2.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The Green Earth foaming skin cleanser was removed from under the sink and placed in a locked area. A designated area was developed and is managed by the Administrative Assistant. Please see Attachment # 15, 16 & 21. Staff will only take enough foaming skin cleanser as to what is to be placed in the dispenser. Program area staff are not to keep extra in their program area. Staff will receive a training on what are poisonous materials by 2/21/2020, attachment #22 will be sent no later than 2/21/2020. 02/21/2020 Implemented
2380.55(a)Program area number #1's oven needs to be cleaned. Inside the oven is covered in burnt food and grease. The trash can in program area #1 near the sink is overflowing and the lid cannot close. Please note that Clinton County Community Connection's staff did remove the trash onsite and replace the trash can with a new trash bag. Program area #1's bathroom was completely unsanitary. The trash receptacle was overflowing with trash and had no lid; the sink, toilet, under the sink, mirror, walls, and the floors needed to be cleaned. The toilet had urine and feces in and around the outside of it. The entire bathroom smelled strongly of urine. Please note, Clinton County Community Connection's staff did remove the trash from this bathroom onsite and replace the trash receptacle with a new trash bag and lid. The second bathroom next to in program area #1, was also very unsanitary. The physical condition of this bathroom was exactly as described as the first bathroom; however, the toilet in this bathroom had blood stains on the toilet seat. Program area #1's bathroom was broken. Upon inspection, when Clinton County Community Connection's staff flushed the toilet, the toilet would not flush correctly and almost over-flowed. Underneath the kitchen sink in program area #3 was unsanitary. It contained black and brown random sized stains from water and other unknown material. Program area #3's woman's bathroom, the first staff left toilet contained feces stains inside the toilet rim and on the toilet seat was a brown unknown substance. The floor in this bathroom had large pockets of dust by the sink. The small, white container that holds clothing, was dirty and sticky. The mirror in the bathroom was filled with old water splash marks and soap marks. The changing room in program #3's toilet had a large, dark stained ring on the inside of the toilet. The toilet was filled with dirty water. The toilet was unsanitary having urine stains and hair on it. The various equipment located in the changing room that is used assist in changing the individuals were also dusty and looked like they had not been wiped with anti-bacterial cloth for some time. The storage closet in this room had a very strong foul smell.Clean and sanitary conditions shall be maintained in the facility.Program Area #1s oven was cleaned on 11/26/2019. Please see Attachment #9. Monthly checks of the facility oven¿s will be performed to ensure cleanliness. Director of Quality Assurance (MT) or designee will be responsible for checking all facility ovens; Program Area staff will ensure that ovens are cleaned within 24 hours of notice. A Monthly checking chart will be sent no later than March 15, 2020 as attachment # 10. Clinton County Community Connection's staff did remove the trash onsite and replace the trash can with a new trash bag. Program Area 1 purchased a bigger trash receptacle with a lid. Please see Attachment # 5. Instructions for Program area daily cleaning was developed to ensure staff are checking program areas at designated times daily for cleanliness and will be verified weekly by the Pathways Supervisor (TM), please see Attachment # 6 for copy of instructions. All pathways staff were trained by 12/30/2019, please see Attachment # 7. Program area #1s bathrooms 1 and 2 were cleaned thoroughly on 11/25/2019. Please see Attachment # 11 & 12. A Bathroom check list with instructions was developed to ensure staff are checking bathrooms at designated times daily for cleanliness and will be verified weekly by the Pathways Supervisor (TM), please see Attachment # 13 for copy of instructions. All pathways staff were trained by 12/30/2019, please see Attachment # 7. Please see Attachment # 14 of the checklist. Program Area #1s bathroom was looked at by maintenance on 11/25/2019, the maintenance worker informed Director of Quality Assurance (MT), that he checked both the toilet and the sewer line and there were no blockages. He was able to flush the toilet after 3 tries. A plumber is scheduled to look into the restroom issue on 2/13/2020. A copy of the plumber visit will be sent once obtained as Attachment #3. The agency has hired a person for daily housekeeping on 12/18/2019, Please see Attachment # 8 for hire date verification and Job description. Underneath the sink in Program area #3s kitchen was cleaned on 11/25/2019, please see attachment # 15 & 16. Instructions for Program area daily cleaning was developed to ensure staff are checking program areas at designated times daily for cleanliness and will be verified weekly by the Pathways Supervisor (TM), please see Attachment # 6 for copy of instructions. All pathways staff were trained by 12/30/2019, please see Attachment # 7. Program area #3s womans bathroom was cleaned thoroughly on 11/25/2019. Please see Attachment #17. A Bathroom check list with instructions was developed to ensure staff are checking bathrooms at designated times daily for cleanliness and will be verified weekly by the Pathways Supervisor, please see Attachment # 13 for copy of instructions. All pathways staff were trained by 12/30/2019, please see Attachment # 7. Please see Attachment # 14 of the checklist. The agency has hired a person for daily housekeeping on 12/18/2019, Please see Attachment #8 for hire date verification and Job description. The changing room in Program area #3 was cleaned thoroughly on 11/25/2019 to include equipment and toilet. Please see Attachment #18. The storage closet was cleaned out and shelves were put in for storage and organization, please see attachment #19. Instructions for changing room daily cleaning was developed to ensure staff are checking changing at designated times daily for cleanliness and will be verified weekly by the Pathways Supervisor (TM), please see Attachment # 20 for copy of instructions. All pathways staff were trained by 12/30/2019, please see Attachment # 7. The agency has hired a person for daily housekeeping on 12/18/2019, Please see Attachment # 8 for hire date verification and Job description. 03/15/2020 Implemented
2380.55(d)Program area #1's trash receptacle was overflowing with trash and had no lid.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.Clinton County Community Connection's staff did remove the trash onsite and replace the trash can with a new trash bag. Program Area 1 purchased a bigger trash receptacle with a lid. Please see Attachment # 5. Instructions for Program area daily cleaning was developed to ensure staff are checking program areas at designated times daily for cleanliness and will be verified weekly by the Pathways Supervisor (TM), please see Attachment # 6 for copy of instructions. All pathways staff were trained by 12/30/2019, please see Attachment # 7. 12/30/2019 Implemented
2380.58(a)Program area #1's bathroom was broken. Upon inspection, when Clinton County Community Connection's staff flushed the toilet, the toilet would not flush correctly and almost over-flowed. The refrigerator in program area #3 is out-of-order.Floors, walls, ceilings and other surfaces shall be in good repair.Program Area #1s bathroom was looked at by maintenance on 11/25/2019, the maintenance worker informed Director of Quality Assurance (MT), that he checked both the toilet and the sewer line and there were no blockages. He was able to flush the toilet after 3 tries. A plumber is scheduled to look into the restroom issue on 2/13/2020. A copy of the plumber visit will be sent once obtained as Attachment #3. The refrigerator was removed from the facility and disposed of on 2/5/2020. Please see Attachment # 4. 02/13/2020 Implemented
2380.63(b)Program area #2's door to the changing area the bottom right side, there are two, three deep scratches, approximately three inches deep, at the bottom of the right-side of this door. Also, on the same door, there is a four-inch-long, one-inch deep scratch approximately three inches from the floor of this door.Screens, windows and doors shall be in good repair.Program Area #2s door to the changing room was replaced on 2/5/2020, please see Attachment # 1. The new door has a kick plate to prevent future damage to the new door. Monthly checks of the facility interior doors will be performed to ensure doors within the facility are in good repair. Director of Quality Assurance (MT) or designee will be responsible for checking all internal doors; if issues arise its to be addressed on a maintenance form and submitted to the CEO (SM) or designee. A monthly checking chart will be sent no later than March 15, 2020 as Attachment # 2. 03/15/2020 Implemented
SIN-00151555 Renewal 05/02/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)Freezer in Area # 2 had 2 purple stains and white powdery substance on bottom of freezer. Freezer in area # 3 had creamy substance which appeared to be mayonnaise on bottom of freezerClean and sanitary conditions shall be maintained in the facility.The freezers in Pathways areas #2 and #3 were cleaned on 5/03/2019 and pictures were taken on 5/06/2019 to reflect this, please see attachments #22 and 23. Staff in areas 2 and 3 of Pathways were trained on the revised Procedure for maintaining sanitary refrigerators on 5/15/2019, please see attachment # 24. All Program Instructors for day services will also be trained on the Procedure for maintaining sanitary refrigerator¿s no later than 5/20/2019. All future instructors will receive this training during orientation. A tracking sheet has been developed to be used daily and will be verified by the supervisor or designee on a weekly basis. The daily check sheet will be sent no later than 6/03/2019 as attachment # 25. 06/03/2019 Implemented
2380.58(a)13 x 13 patch unpainted in right bathroom by main entrance.Floors, walls, ceilings and other surfaces shall be in good repair.The 13 x 13 patch on the wall in the right bathroom by main entrance was painted on 5/05/2019, a picture were taken on 5/06/2019 to show the repair, please see Attachment # 19. A door stop has been added to keep the door handle from punching a hole in the wall, this was installed on 5/05/2019. A picture of the installed door stop was taken on 5/06/2019, please see attachment # 20. Monthly checks of the facility will be performed to ensure that facility floors, ceilings, and other surfaces are in good repair. Program Specialist¿s or designee will be responsible for checking their designated areas, if areas need to be addressed a maintenance form will be filled out and submitted to the CEO (SM). A monthly checking chart will be sent no later than 6/03/2019 as attachment # 21. 06/03/2019 Implemented
2380.82Left egress door in area #3 (Haven area) does not open. Locking mechanism/bar is broken. Exit # 7 door is broken on top right of door. Sticking to frame when opening.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Both the Left egress door in Haven area # 3 and Exit # 7 were repaired on 5/06/2019. To ensure no future issues related to egress, new hard was ordered on 5/06/2019 for Haven area # 3 door, please see attachment # 26. Haven area # 3 door will receive compete new hardware no later than 5/30/2019, pictures will be taken of the door¿s new hardware and sent no later than 6/03/2019, please see attachment #27. Weekly checks of the facility Exits will be performed to ensure that facility exits from rooms and from the building are unobstructed. CEO (SM) or designee will be responsible for checking all exits; if issues arise it¿s to be addressed on a maintenance form will be filled out and submitted to the CEO (SM) or designee. A weekly checking chart will be sent no later than 6/03/2019 as attachment # 28. 06/03/2019 Implemented
2380.91(a)There is no documentation of Individual #14's initial fire safety training upon 12/05/18 admission. Initial Fire Safety Form not dated. No Documentation of Individual #13's receiving fire safety training in 04/2018. His most recent training is 04/03/19.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Program Specialist (BS) was retrained on regulation 91 (a) on 5/14/2019, please see attachment # 15. Individual #14 was provided with initial fire safety training again on 5/15/2019 since there was no other documentation to verify the date of the original initial fire safety, please see attachment # 16. Through Individual #13¿s monthly documentation for April 2018 it was verified that he received his annual fire safety training on 4/03/2018, please see attachment # 17. BS was retrained on the use of correct documentation form on 5/14/2019, please see attachment # 15. The proper documentation form was used on 4/03/2019, please see attachment # 18. All fire safety tracking is the responsibility of the PS, CEO (SM) or designee will audit the fire safety book every 6 months to ensure that all client¿s fire safety dates are present in the file. An audit will be completed on at least 3 of BS¿s individual files quarterly for duration of 1 year by Quality Director (MT) or designee to ensure that all documents that requires signatures and dates are complete. 05/15/2019 Implemented
2380.111(c)(4)Individual #11's 04/22/19 physical exam did not include a vision or hearing screening On the most recent physical for Individual #8 dated 5/23/18, the hearing and vision screening was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialists (BB) and (TP) were retrained on Regulation 111 (c) (4) on 5/13/2019, please see Attachment # 12. BB and TP were also trained on the new Procedure for maintaining up to date annual physical documentation on 5/14/2019, please see attachment # 7. Individual¿s #11¿s 4/22/2019 annual physical exam form was updated on 5/03/2019 to include information in regards to recommendations by the physician for vision and hearing screening, see Attachment # 13. Individual¿s #8¿s 5/23/2018 annual physical exam form was updated on 5/03/2019 to include information in regards to recommendations by the physician for vision and hearing screening, see Attachment # 14. An audit will be completed on at least 3 of TP¿s individual files quarterly for duration of 1 year by Quality Director (MT) or designee to ensure that documents are located in the correct location and clearly seen. All audit reviews will be shared with BB and TP¿s supervisor, CEO (SM). 05/14/2019 Implemented
2380.111(c)(5)Annual physical exam for individual #8 dated 5/17/17 shows a TB test read date of 5/13/15, indicating that the next series of TB tests should have been completed by 5/13/17 however documentation from Susquehanna Health indicates that the individuals TB was not completed again until 6/4/18.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.Individual #8 had a TB by Mantaux screening completed on 5/19/2017. It was in the individual¿s record however, was mixed in between other documents and missed during the file audit. It was presented at the end of the exit conference on 5/03/2019. Please see attachment #11 for same copy. An audit will be completed on at least 3 of TP¿s individual files quarterly for duration of 1 year by Quality Director (MT) or designee to ensure that documents are located in the correct location and clearly seen. All audit reviews will be shared with TP¿s supervisor, CEO (SM). 05/03/2019 Implemented
2380.111(c)(7)Individual #10's most recent physical dated 1/22/19 under "recommendations for health maintenance" was left blank. Individual # 7's most recent physical dated 10/24/18 under "recommendations for health maintenance" was left blank. Individual #3's most recent physical dated 9/7/18 under "recommendations for health maintenance" was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Program Specialists (NC), (MVB) and (TP) were retrained on Regulation 111 (c) (7) on 5/13/2019, please see Attachment # 6. NC, MVB and TP were also trained on the new Procedure for maintaining up to date annual physical documentation on 5/14/2019, please see attachment # 7. All Program Specialists for day services will also be trained on the Procedure for maintaining up to date annual physical documentation no later than 5/20/2019, all future Program Specialist will receive this training during PS orientation. Individual¿s #10¿s 1/22/2019 annual physical exam form was updated on 5/03/2019 to include recommendations for health maintenance, see Attachment # 8. Individual¿s #7¿s 10/24/2018 annual physical exam form was updated on 5/03/2019 to include recommendations for health maintenance, see Attachment # 9. Individual¿s #3¿s 9/07/2018 annual physical exam form was updated on 5/03/2019 to include recommendations for health maintenance, see Attachment # 10. An audit will be completed on at least 3 of NC, MVB and TP¿s individual files quarterly for duration of 1 year by Quality Director (MT) or designee to ensure proper completion of physicals is occurring. All audit reviews will be shared with NC, MVB and TP¿s supervisor, CEO (SM). 05/14/2019 Implemented
2380.181(a)Individual #12's DOA was 10/30/18 and did not have an assessment in the record.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.Program Specialist BB was retrained on Regulation 181 (a) and her responsibilities related to the completion of Assessments to occur within 60 days from admission date on 5/10/2019, please see attachment # 3. BB completed individual #12¿s Initial Assessment on 5/03/2019 and it was reviewed with individual #12 on 5/07/2019, please see attachment# 4. BB has also supplied a completed assessment that was done within the correct time frame for individual (BF), please see attachment # 5. An audit will be completed on at least 3 of BB¿s individual files quarterly for duration of 1 year by Quality Director (MT) or designee to ensure all areas of the assessment are complete. All audit reviews will be shared with BB¿s supervisor, CEO (SM). 05/10/2019 Implemented
2380.181(e)(5)Individual #11's assessment dated 05/14/18 does not specify her ability to self-administer medications. Assessment states that she "does not take medication at Day Program."The assessment must include the following information: The individual's ability to self-administer medications.Program Specialist (BB) was retrained on 5/10/2019 on regulation 181 (e) (5), see Attachment # 1. BB updated individual #11¿s Assessment on 5/03/2019 and it was reviewed with individual #11 on 5/06/2019 to address individual #11¿s ability to self-administer medications. Please see attachment# 2. An audit will be completed on at least 3 of BB¿s individual files quarterly for duration of 1 year by Quality Director (MT) or designee to ensure all areas of the assessment are complete. All audit reviews will be shared with BB¿s supervisor, CEO (SM). 05/10/2019 Implemented
SIN-00131165 Renewal 05/15/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff # 5 was hired on 08/02/17 and did not apply for criminal check until 03/27/18.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Staff #5 not receiving a PA back ground check was already known; as a result the HR director (DZ) implemented an Application/Contractors checklist for all pre-hires in March 2018. Included in the POC is a copy of two completed checklists on new hires, see Attachment #53 & 54. DZ received training on regulation 20 (a) on 5/24/2018, see Attachment # 55. 05/24/2018 Implemented
2380.53(b)A spray bottle with blue liquid was located in Haven 2 cleaning supply area. Not in original container.Poisonous materials shall be stored in their original, labeled containers.Program Specialist (TP) was trained on regulation 53(b) on 5/23/2018, see Attachment #50. Program Specialists (MM, MVB), Coordinator (BR), and support staff in Haven Area 2 were all trained on regulation 53(b) on 5/24/2018, see Attachment #51. Monthly checks of the facility will be performed to ensure that poisonous materials are stored in their original, labeled containers. Starting in June 2018, the program Specialist¿s or designee will be responsible for checking their designated areas. A monthly checking chart will be sent no later than 6/20/2018 as Attachment #52. 06/20/2018 Implemented
2380.58(a)Men's bathroom lower area had paint missing from wall below hand towel area.Floors, walls, ceilings and other surfaces shall be in good repair.Repairs to the wall in the men¿s bathroom in Haven Area 2 was completed on 5/23/2018, 2 pictures were taken on 5/24/2018 to show the repairs, see Attachments #45 & #46. Program Specialist (TP) was trained on regulation 58(a) on 5/23/2018, see Attachment #47. SM, Program Specialists (MM, MVB), Coordinator (BR), and support staff in Haven Area 2 were all trained on regulation 58(a) on 5/24/2018, see Attachment #48. Monthly checks of the facility will be performed to ensure that facility floors, ceilings, and other surfaces will be in good repair. Starting in June 2018, the program Specialist¿s or designee will be responsible for checking their designated areas, if areas need to be addressed a maintenance form will be filled out and submitted to the CEO (SM). A monthly checking chart will be sent no later than 6/20/2018 as Attachment #49. 06/20/2018 Implemented
2380.59(b)Bathroom in haven 3 area had water temperature of 125.1 degrees F. Kitchen sink in Haven 3 area temp was 125.6 degrees F.Hot water temperatures in areas accessible to individuals may not exceed 120°F.CEO (SM) adjusted the water temperature on 5/16/2018 to ensure that the water temperature was below 120 degrees in Haven Area 3¿s kitchen and bathroom. Program Specialist (TP) was trained on regulation 59(b) on 5/23/2018, see Attachment #41. SM, Program Specialists (BB, BS, NC, MM, MVB), and Coordinators (TM, JH, BR) were all trained on regulation 59(b) on 5/24/2018, see Attachment #42. Implementation of a monthly water temperature check was implemented on 5/24/2018 to check the water temperature for all faucets at the facility. Included in the POC is the May reading for Haven Area 3¿s bathroom and Kitchen which were checked by MT, see Attachments #43 & 44. Starting in June 2018, the program Specialist¿s or designee will be responsible for checking the water temperature and filling out the chart. 05/24/2018 Implemented
2380.111(c)(8)Individual # 4's physical dated 01/24/18 does not identify physical limitations. Space left blank.The physical examination shall include: Physical limitations of the individual.Individual #2 is the correct individual for this citation. Program Specialist (BB) was retrained on Regulation 111 (c) (8) on 5/24/2018, see Attachment #37. Individual¿s #2¿s 1/24/2018 annual physical exam form was updated on 5/17/2018 to include the individual¿s physical limitations, see Attachment #38. An audit will be completed on at least 2 of BB's books quarterly for duration of 1 year by MT or designee to ensure physical exams are filled out in its entirety. 05/24/2018 Implemented
2380.111(c)(10)Individual # 1's diet is NOS and he/she has a tracheotomy tube. He/She also is diagnosed with a seizure disorder and is prescribed Diastat PRN. He/she has a seizure protocol in place. Physical dated 03/29/18 does not include aforementioned information.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist (NC) was retrained on Regulation 111 (c) (10) on 5/24/2018, see Attachment #39. Individual¿s #1¿s 3/29/2018 annual physical exam form was updated on 5/18/2018 to include appropriate information pertinent to diagnosis and treatment in case of an emergency, see Attachment #40. An audit will be completed on at least 2 of NC's books quarterly for duration of 1 year by MT or designee to ensure physical exams are filled out in its entirety with appropriate information. 05/24/2018 Implemented
2380.111(c)(10)Individual # 4's 01/26/18 physical does not provide information pertinent to diagnosis in case of an emergency. States Dial 911.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #2 is the correct individual for this citation. Program Specialist (BB) was retrained on Regulation 111 (c) (10) on 5/24/2018, see Attachment #39. Individual¿s #2¿s 1/24/2018 annual physical exam form was updated on 5/17/2018 to include information pertinent to diagnosis and treatment in case of an emergency, see Attachment #38. An audit will be completed on at least 2 of BB's books quarterly for duration of 1 year by MT or designee to ensure physical exams are filled out in its entirety with appropriate information. 05/24/2018 Implemented
2380.121(b)Individual # 1's medication cabinet was not locked.Prescription and nonprescription medications shall be kept in an area or container that is locked.Program Specialist (NC) was retrained on regulation 121 (b) on 5/24/2018, see Attachment #34. NC developed a signature sheet that is to be completed in the mornings and in the afternoon to ensure that Individual #1¿s medicine cabinet is being locked; this was implemented on 5/21/2018, see Attachment #35. Support Staff in Individual #1¿s room were trained on the new procedure on 5/21/2018, see Attachment #36. Random checks of individual #1¿s medicine cabinet will be done by NC or designee to ensure the health, safety and welfare of the individuals receiving services. 05/24/2018 Implemented
2380.173(7)Individual # 6 did not have a copy of current ISP in record. 05/17/17 ISP in record. Most recent ISP last updated 05/03/18 not contained in record.Each individual¿s record must include the following information:  A copy of the current ISP.Program Specialist (MM) was retrained on regulation 173 (7) on 5/24/2018, see Attachment #26. MM printed out individual #6¿s ISP on 5/16/2018 and place in her record, see Attachment #27 and trained staff on the plan by 5/18/2018, see Attachment #28. A meeting was held for Program specialists (BB, BS, NC, MM, and MVB) on 5/24/2018 to address a process for ensuring current ISP¿s are located in the individual¿s record, see Attachment #29. A procedure has been written to address this process, see Attachment #30. This Procedure was written by MT and will be reviewed with program specialists (BB, BS, NC, MM, and MVB) on implementation date of 6/04/2018 as Attachment #31 and sent in no later than 6/08/2018 and with program specialist TP when she is back to work as Attachment #32 to be sent in no later than 8/01/2018 and will be added to New Program Specialist Orientation. An audit will be completed on at least 2 of MM's books quarterly for duration of 1 year by MT or designee to ensure current ISP¿s are located in the individual¿s record. 08/01/2018 Implemented
2380.173(9)Individual # 4's assessment dated 05/05/17 does not reflect the ISP dated 09/24/17 regarding unsupervised time.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program Specialist (TP) was retrained on 5/23/2018 on regulation 173(9), see Attachment #33. TP updated Individual #4¿s Assessment and ISP to better address his supervision care needs, see Attachments #15 & #16. Haven Support Staff were trained on Individual #4¿s Supervision level by 5/24/2018, see Attachment #17. An email was sent the Individual #4¿s Supports Coordinator to address the changes, see Attachment #18. The Supports Coordinator changed the Supervision level in the ISP on 5/30/2018, see Attachment #19, a new copy of the updated ISP was placed in individual #4¿s record on 5/30/2018. An audit will be completed on at least 2 of TP's books quarterly for duration of 1 year by MT or designee to ensure Supervision care needs are written appropriately in the ISP and assessments. 05/30/2018 Implemented
2380.181(e)(7)Individual # 4's 09/04/17 assessment does not indicate his/her ability to move away from heat sources.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Individual #2 is the correct individual for this citation. Program Specialist (BB) was retrained on 5/24/2018 on regulation 181 (e) (7), see Attachment #20. BB updated individual #2¿s Assessment on 5/16/2018 to address whether or not the individual had the ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated, see Attachment #21. An audit will be completed on at least 2 of BB's books quarterly for duration of 1 year by MT or designee to ensure assessments are addressing the ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. 05/24/2018 Implemented
2380.181(e)(13)(v)Individual # 2's 09/04/17 assessment does not indicate progress and growth in the area of recreation.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.Program Specialist (BB) was retrained on 5/24/2018 on regulation 181 (e)(13)(v), see Attachment #22. BB updated individual #2's Assessment on 5/16/2018 to address progress over the last 365 calendar days and current level in Recreation, see Attachment #21. An audit will be completed on at least 2 of BB's books quarterly for duration of 1 year by MT or designee to ensure assessments are addressing progress in the area of recreation. 05/24/2018 Implemented
2380.181(e)(13)(vi)Individual # 4's 09/04/17 assessment does not indicate progress and growth in the area of community integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Individual #2 is the correct individual for this citation. Program Specialist (BB) was retrained on 5/24/2018 on regulation 181 (e)(13)(vi), see Attachment #23. BB updated individual #2¿s Assessment on 5/16/2018 to address progress over the last 365 calendar days and current level in community integration, see Attachment #21. An audit will be completed on at least 2 of BB's books quarterly for duration of 1 year by MT or designee to ensure assessments are addressing progress in the area of community integration. 05/24/2018 Implemented
2380.181(e)(14)Individual # 7's annual assessment date 11/07/17 does not indicate his/her ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Program Specialist (BB) was retrained on 5/24/2018 on regulation 181(e)(14), see Attachment #24. BB updated individual #7¿s Assessment on 5/17/2018 to address the individual¿s knowledge of water safety and ability to swim, see Attachment #25. An audit will be completed on at least 2 of BB's books quarterly for duration of 1 year by MT or designee to ensure assessments are addressing the individual¿s knowledge of water safety and ability to swim. 05/24/2018 Implemented
2380.183(4)Individual # 4 receives 2:3 staffing when going into the community. He/She can go off with a responsible peer up to 30 minutes and then check in with staff. It is unclear what constitutes a responsible peer and how individual # 4 would check in with staff. Individual # 4 may go into another aisle at a store when shopping with staff but no direction as to how or when they should check in with each other.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.Program Specialist (TP) was retrained on 5/23/2018 on regulation 183(4) , see Attachment #14. TP updated Individual #4¿s Assessment and ISP to better address his supervision care needs. Please see Attachments #15 & #16. Haven Support Staff were trained on Individual #4¿s Supervision level by 5/24/2018, see Attachment #17. An email was sent to Individual #4¿s Supports Coordinator to address the changes, see Attachment #18. The Supports Coordinator changed the Supervision level in the ISP on 5/30/2018, see Attachment #19, a new copy of the updated ISP was placed in individual #4¿s record on 5/30/2018. Individual #4¿s next ISP review is scheduled for 6/28/2018 which will be completed by Program Specialist (NC) who is covering for TP while she is off on maternity leave. It will be sent no later than 7/06/2018 as Attachment #8. An audit will be completed on at least 2 of TP's books quarterly for duration of 1 year by MT or designee to ensure Supervision care needs are written appropriately in the ISP and assessments. 06/28/2018 Implemented
2380.186(a)Individual # 4 had ISP reviews on 06/01/17, 09/01/17, 01/22/18 and 02/27/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Individual #2 is the correct individual for this citation. Program Specialist BB has been retrained on Regulation 186 (a) and her responsibilities related to the completion of ISP reviews on 5/24/2018, see Attachment # 1. Quality Manager (MT) is scheduled to meet with BB in June to review all her ISP review dates to ensure they are correct for future reviews. Signature sheet of this training will be sent in no later than 6/20/2018 as Attachment #2. BB has supplied 4 reviews for individual TW to show where she did complete 4 ISP reviews in a timely manner, see Attachments #3, #4, #5, and #6. An audit will be completed on at least 2 of BB's books quarterly for duration of 1 year by MT or designee to ensure ISP reviews are being completed in a timely manner. 06/20/2018 Implemented
2380.186(a)Individual # 4 has unsupervised time in the community. This information is not included in ISP reviews during the annual review year.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Program Specialist (TP) has been retrained on regulation 186 (a) and her responsibilities related to supervision care needs and progress towards independence on 5/23/2018, see Attachment #7. Individual #4¿s next ISP review is scheduled for 6/28/2018 which will be completed by Program Specialist (NC) who is covering for TP while she is off on maternity leave. It will be sent no later than 7/06/2018 as Attachment # 8. Included in this POC is an ISP review for individual (RH) dated 3/19/2018 showing where her supervision care needs and progress towards independence has been addressed in the ISP review completed by Program Specialist (MBV), see Attachment #9. A meeting was held for Program specialists (BB, BS, NC, MM, and MVB) on 5/24/2018 to address where in the ISP review to add progress towards independence related to supervision care needs, see Attachment #10. Everyone agreed that it will be addressed under the Supervision section of the review in order to show consistency with the ISP reviews; this procedure written by MT(Attachment # 11) will be reviewed with program specialists (BB, BS, NC, MM, and MVB) on implementation date of 6/04/2018 as Attachment #12 and sent in no later than 6/08/2018 and reviewed with program specialist (TP) when she is back to work as Attachment #13 to be sent in no later than 8/01/2018 and will be added to New Program Specialist Orientation. An audit will be completed on at least 2 of TP's books quarterly for duration of 1 year by MT or designee to ensure supervision care needs are addressed appropriately in the ISP review. 06/04/2018 Implemented
SIN-00111359 Unannounced Monitoring 03/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff # 14 fire safety training occured on 04/20/15 and not again unto 05/02/16. Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Staff #14 had fire safety training on 5/02/2016 and received his annual fire safety training again in 2017 on 4/05/2017 within 365 days. Please see attachments #30 & #31. CCCC has hired a designated trainer for the agency to ensure staff are receiving training in a timely manner to safeguard against any missed training dates in the future. 04/05/2017 Implemented
2380.53(a)Adapt Paste was found unlocked in changing room cabinet. (Contact Poison Control). Right Guard Extreme Fresh Deodorant, Colgate 2.8 oz toothpaste and Crest .85 oz toothpaste found in program room filng cabinet unlocked (Contact Poison Control). Great Valve Fresh Scent disinfecting wipes found in filing cabinet of Program Room (Contact Poison Control). First Aid kit found in Ladies room of Sensory area unlocked (Contact Poison Control). First Aid kit found on bottom shelf of pantry in kitchen unlocked (Contact Poison Control 2 Cycle laundry detergent found on floor by laundry room. (Contact Poison Control). Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Adapt paste in the changing room was removed on 3/30/2017 and placed in a locked cabinet in the individual's program area until a locked cabinet is purchased for the changing room. The right guard extreme fresh deodorant, Colgate 2.8 oz toothpaste and Crest.85oz toothpaste were removed on 3/30/2017 and have been placed in a lock cabinet right outside of that individuals program area so that he can still easily access his hygiene supplies. CCCC will be purchasing individual locking boxes for individuals with hygiene kits so that their hygiene supplies can be easily accessed for them when they need to utilize their items to increase independence. The great value fresh scent disinfecting wipes was removed on 3/30/2017 and placed in a locked cabinet. CCCC will be purchasing cabinets for each area in the facility that will only be designated for cleaning supplies and will remain locked at all times. Having only one designated area for cleaning supplies in each room with reduce the risk of cleaning supplies being accessible to individuals who are at risk. The first aid kit in the restroom in the sensory room was removed on 3/30/2017 and placed in a locked cabinet in the sensory room. The first aid kit in the kitchen was removed on 3/30/2017 and was placed in a locked closet. The agency will be purchasing containers that lock for all first aid kits for the agency. Designated areas will house the first aid kits and the area will be clearly labeled to alert people as to where they are located. The 2 cycle laundry detergent was removed from the laundry room on 3/30/2017 and placed in a locked closet. The agency be purchasing a locked door to be placed in the laundry area. 03/30/2017 Implemented
2380.58(a)Cabinet door handles broken on two cabinets in program area 3. Microwave cabinet missing knob for door. TV stand missing knob for door. Kitchen cabinet missing door for cabinet next to stove. Filing Cabinet in Haven room broken. Floors, walls, ceilings and other surfaces shall be in good repair.The two cabinets in program area 3 will be replaced with new cabinets that were purchased on 4/12/2017. Please see attachment #25. The microwave cabinet in program area 3 was fixed. Please see attachment #26. The TV stand will be replaced with a new cabinet that was purchased on 4/12/2017. Please see attachment #27. A cabinet door was purchased and placed on the cabinet next to the stove in the kitchen on 4/11/2017. Please see attachment #28. The broken filing cabinet in the Haven was replaced with a new filing cabinet on 4/10/2017. Please see attachment #29. 04/12/2017 Implemented
2380.111(c)(8)Repeat 3/7/16: Individual # 9's 04/04/16 physical did not indicate physical limitations for activities. The section was left blank. The physical examination shall include: Physical limitations of the individual.Program Specialist AR corrected Individual #9's annual physical from 4/04/2016 to address any physical limitations on 4/03/2017. Please see attachment #18 AR also is providing individual #9's current annual physical exam which was completed on 3/20/2017 where the information in regards to physical limitations was provided. Please see attachment #19. AR was retrained on 4/12/2017 in regards to regulation 2380.111(c)(8). Please see attachment #20. Agency nurse was also retrained on 4/12/2017 in regards to regulation 2380.111(c)(8). Please see attachment #21. 04/12/2017 Implemented
2380.111(c)(10)Repeat 3/7/16:Individual # 1's physical dated 05/10/16 did not include info pertinent to diagnosis in case of emergency. Space was left blank on physical. Individual # 10's 04/5/16 physical exam left the Medical information pertinent to diagnosis and treatment in case of emergency blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist TP corrected Individual #1's annual physical from 5/10/2016 to address information pertinent to diagnosis and treatment in case of emergency on 4/03/2017. Please see attachment #22. TP was retrained on 4/12/2017 in regards to regulation 2380.111(c)(10). Please see attachment #23. Agency nurse was also retrained on 4/12/2017 in regards to regulation 2380.111(c)(10). Please see attachment #24. Program Specialist MM corrected Individual #10's annual physical from 4/05/2016 to address information pertinent to diagnosis and treatment in case of emergency on 3/30/2017. Please see attachment #25. MM was retrained on 4/12/2017 in regards to regulation 2380.111(c)(10). Please see attachment #26. Agency nurse was also retrained on 4/12/2017 in regards to regulation 2380.111(c)(10). Please refer to attachment #24. 04/12/2017 Implemented
2380.128(d)Staff number 15 was med trained on 07/15/15 and not again until 08/06/16. A staff person who administers prescription medications or insulin injections to individuals shall complete the Medications Administration Course Practicum annually.Staff #15 received initial medication administration training and was certified as of 8/06/14. Please see attachment #32. Staff #15 stayed current with passing medication monthly and the Medication Trainers stayed within time frames for observations every 6 months and reviews every quarter. The initial training date should have been used as his recertification date in 2015 instead of the date of 7/15/15 that was used by med trainer CH. Please see attachment #33. CH is no longer a med trainer at the agency and med trainer DL took over. DL kept with staff #15's original certification date of 8/6 for 2016. Please see attachment #34. DL emailed The Medication Administration Training help desk on 4/12/2017 for verification that the initial certification date could stay as the date for recertification and the help desk was able to verify. Please see attachment # 35. There is a Med Admin meeting on 4/19/2017 with the agency med trainers who will be discussing moving forwarding making sure all staff's recertification date stays the same for recertification from year to year. 04/19/2017 Implemented
2380.173(9)Repeat 3/7/16: Individual # 6 is currently prescribed Diazepam 10 mg Rectal Gel for seizures. Individual # 6's Individual Support Plan (ISP) states that he/she is presctibed Diazepam 5 mg. Individual # 6's seizure protocol written by his/her physician is not consistent with the protocol documented in his/her ISP. The seizure protocol in ISP states to administer if Individual # 6 has several consexutive seizures in a short period of time. The physician protocl states if Individual #6 has 3 or more consecutive seizures to administer. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program Specialist MVB wrote a new seizure protocol pertaining to day program on 3/29/2017; it was sent to Individual #6's Neurologist. Please see attachment #13. The Neurologist confirmed that individual #6 is only to receive 5mg of Diazepam not 10mg and is to receive the Diazepam 5 mg if he were to have more than 3 consecutive seizures or if 1 seizure lasts longer than 5 minutes. Direct Support staff were trained on the new protocol on 3/29/2017. Please see attachment #14. The pharmacy provided CCCC with the correct dose of the Diazepam 5 mg on 3/29/2017. A new label was provided with all the correct information in regards to the dosage and PRN requirements. Please see attachment # 15. MVB updated Individual #6's ISP to match the new seizure protocol and sent it to the SCO on 4/07/2017. Please see attachment #16. MVB was retrained on 4/12/2017 in regards to regulation 2380.173(9). Please see attachment #17. 04/12/2017 Implemented
2380.176(a)Program books in filing cainet of program area were undattended and unlocked. Kitchen Filing Cabinet had individual outcome documentation unlocked and accessible. Individual records shall be kept locked when they are unattended.All the individual's books in each program have designated places for all program books housing information in regards to the individuals in central locations, these locations are all cabinets which can lock and will remain locked when staff is not in possession of the program books. Documentation in the Kitchen has been moved into a locking filing cabinet and will remain locked when staff is not in possession of the documentation. This occurred on 3/31/2017. Program Specialists of individuals in each room addressed this with the direct support staff. 03/31/2017 Implemented
2380.181(a)Individual # 8's 10/10/16 assessmend was completed later than 60 days after his/her 08/01/16 admission.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.Program Specialist MM is submitting an assessment for individual #1 to show where he has completed an assessment within 60 days from admission. Individual #1's admission date was 9/06/2016 and an assessment was completed on 10/06/2016 and reviewed with Individual #1 on 10/07/2016. Please see attachment #3. MM was retrained on 4/12/2017 in regards to regulation 2380.181(a). Please see attachment #4. 04/12/2017 Implemented
2380.181(e)(7)Individual # 3's annual assessment date 09/22/16 did not include his/her ability to sense and move away from heat sources. Individual # 4's 06/13/16 assessment does not state his ability to sense and move away quickly from heat sources. Individual # 7's 04/29/16 assessment does not indicate his/her ability to move away from heat sources. The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Program Specialist MT made an addendum to Individual #3's assessment on 3/31/2017 to include his ability to sense and move away quickly from heat sources. Please see attachment #5. MT received retraining on 4/12/2017 in regards to regulation 2380.181(e)(7). Please see attachment #6. Program Specialist MVB made an addendum to Individual #4's assessment on 3/31/2017 to include his ability to sense and move away quickly from heat sources. Please see attachment #7. MVB received retraining on 4/12/2017 in regards to regulation 2380.181(e)(7). Please see attachment #8. Program Specialist AR made an addendum to Individual #7's assessment on 3/28/2017 to include her ability to sense and move away quickly from heat sources. Please see attachment #9. MT received retraining on 4/12/2017 in regards to regulation 2380.181(e)(7). Please see attachment #10. 04/12/2017 Implemented
2380.181(f)Repeat 3/7/16:Individual # 2's 10/25/16 assessment was sent to the SC on 10/20/16 and not 30 days prior to the Individual Support Plan meeting held on 09/27/16.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).Program Specialist TP is submitting an assessment for individual #1 to show where she has completed an assessment and sent it to the SCO 30 days prior to the ISP meeting. Individual #1's ISP meeting is scheduled for 5/16/2017 and the assessment was completed, reviewed with Individual #1 and send to the SCO on 3/7/2017. Please see attachment #11. TP was retrained on 4/12/2017 in regards to regulation 2380.181(f). Please see attachment #12. 04/12/2017 Implemented
2380.186(c)(2)Repeat 3/7/16:Individual # 9's Seen plan progress was not reported on the 12/20/16 Quarterly. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Specialist AR made an addendum to Individual #9's 12/20/2016 quarterly review on 4/07/2017. The addendum addresses the SEEN plan in the Significant Behaviors section of the review to include progress. Please see attachment #1. AR also received retraining on 4/12/2017 in regards to regulation 2380.186(c)(2). Please see attachment #2 04/12/2017 Implemented
SIN-00091050 Renewal 03/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.17(d)(1)Individual # 7 did not have a HCSIS report filed for neglect of supervision on 12/18/15. ISP states that he/she did not return to the program on time. No ducumentation of when he/she left the program. The facility shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department, within 72 hours after an unusual incident occurs, to: The county mental health and mental retardation program of the county in which the facility is located if the individual involved in the unusual incident has mental illness or mental retardation.Program Specialist (TP) will ensure that IM reports are being filed within the required time frame. An EIM report was filed on 3/07/2016 for neglect (not following proper supervision). The investigation was completed on 3/14/2016 and the administrative review was held on 3/15/2016 . The outcome of the investigation was confirmed. TP is required to under go training in regards to supervision, and agency policy and procedures related to incident management and filing reports. She will also be retrained on regulation 2380.17 Reporting unusual incidents. All trainings will occur no later than 4/29/2016. Attachments #71, #72, #73 & #74 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.89(g)Repeat:The fire drill dated 1/21/16 stated that not all individuals evacuated the facility,Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Moving forward the agency will ensure that there is at least 1 successful fire drill evacuation each month. If the individuals do not evacuate within the required time frame of 2 1/2 minutes, then the agency will have continued fire drills within the same month until successful in evacuation. The agency had a successful fire drill on 4/05/2016. All individuals successfully evacuated within 2 1/2 minutes including the individual that did not successfully evacuate on 1/21/2016. Please see attachments #65 & #66. EK and CH received retraining on fire regulations 2380.89 and agency fire safety and evacuation dated 4/04/2016. Please see attachments #67, #68, #69, & #70. 04/05/2016 Implemented
2380.111(a)Repeat: Individual #8's physical was late. It was done on 5/30/14 and then again on 7/2/15. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialist (MT) and LPN (DL) will ensure that individual's annual physical exams are being completed within the required time frame. Two letters are sent along with a copy of the physical exam form, letters inform the individual and caregivers of the required time frames for physical exams. Please see attachments #45 & #46. Individuals that do not receive their annual physical exam within the required time frame will have their services suspended until the required documents are obtained by the agency. A file note will be placed in the record explaining why services were suspended and when services resumed. Please see attachments # 47 & #48 to show another individual's physical exams that was in compliance. MT and DL will complete retraining on Health regulations 2380.111 no later than 4/29/2016. Attachments #49, #50, & #51 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.111(c)(5)Individual #6's tuberculin skin testing conducted on 10/3/14. There was no prior physcial in the record. Individual #7's tuberculin skin testing conducted on 2/24/16 . There was no prior physcial in the record. The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Individual #6's prior physical was in the purged file in error, it has since been placed back in the record. Program Specialist (TP) will ensure that are current dates and prior dates of physical exams, DT immunizations, and TB screenings are present in the individual's file. Please see attachments # 52, #53, #54, #55, & #56. Individual #7's prior physical was in the purged file in error, it has since been placed back in the record. Program Specialist (TP) will ensure that are current dates and prior dates of physical exams, DT immunizations, and TB screenings are present in the individual's file. Individual's 2014 TB screening date is marked as read on 2/13/2014 however it was in different handwriting and not properly documented with a date and initials as to who write it. Please see attachments #57, #58, #59, & #60. There is no record at the individual's PCP's office of him receiving a TB screening in their office in 2014. Individual's family member was contacted to see where individual #7 had his testing done and they stated it was at his PCP's office. Moving forward that agency LPN will secure the appropriate documentation with the required information from the PCP and/or use appropriate documentation on a physical exam by using dates and initials related to the information added to the exam. Please see attachments # 61& #62 to show another individual's TB screening that were in compliance. TP and DL will complete retraining on Health regulations 2380.111 no later than 4/29/2016. Attachments #49, #63, & #51 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.111(c)(8)Individual #7's physcial dated 12/22/16 does not inlcude physcial limitations of the indvidual.The physical examination shall include: Physical limitations of the individual.Physical limitations of individual #7 was added to the physical exam on 4/08/2016 and was documented correctly with the date and initials of who added the information. Please see attachment # 57. This is ensure that the physical exam is up to date with information and will pre-populated onto the 2017 physical exam that is completed by the PCP. TP and DL will complete retraining on Health regulations 2380.111 no later than 4/29/2016. Attachments #49, #63, & #51 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.111(c)(10)Individual #8's physcial does not contain 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.medical information pertinent to diagnosis and treatment in case of an emergency of individual #8 was added to the physical exam on 3/30/2016 and was documented correctly with the date and initials of who added the information. Please see attachment # 64. This is ensure that the physical exam is up to date with information and will pre-populated onto the 2017 physical exam that is completed by the PCP. MT and DL will complete retraining on Health regulations 2380.111 no later than 4/29/2016. Attachments #49, #50, & #51 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.111(c)(11)Repeat: Individual #6's physcial does not cotnain special instructions for an individuals diet. The physical examination shall include: Special instructions for an individual's diet.New diet recommendations of individual #7 was added to the physical exam on 4/06/2016 and was documented correctly with the date and initials of who added the information. Please see attachment # 52. This is ensure that the physical exam is up to date with information and will pre-populated onto the 2017 physical exam that is completed by the PCP. TP and DL will complete retraining on Health regulations 2380.111 no later than 4/29/2016. Attachments #49, #63, & #51 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.113(c)(3)Staff #2's physcial dated 11/13/14 did not list if person is free of serious communicable diseases. The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.Staff #2 had a physical completed on 3/29/2016 will all required information complete including whether the person is free from communicable disease. Please see attachment # 41. Staff #2 and designated HR person will complete retraining on Health regulation 2380.113 no later than 4/29/2016. Attachments #42, #43, & #44 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.128(a)Staff #4 did not complete medication practium from 2014. It is missing 1 observation, 1 practium summary is not completed by CCCC, and were not trained to give medications. A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.Staff #4 was received Med Admin Initial training starting 3/09/2016 through 3/11/2016. Staff #4 completed all criteria for her med admin certification. Please see Attachment #36. Med trainers (DL), (CH) and (AR) will ensure that all staff hired that received med training through another agency will have completed documents that are required to be certified. If not all documents are complete, the employee will need to complete the entire med admin initial training. DL, CH, & AR will complete retraining on regulations 2380.127-128 in regards to med admin and med training requirements no later than 4/29/2016. Attachments #37, #38, #39 & #40 will show the completion of the training and will be sent upon expected completion. 04/29/2016 Implemented
2380.173(1)(v)Individual #1, #3, and #8 did not have a dated photo located in the record. Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Program Specialist (MT) and (EK) will ensure that there are dated photos located in the records. EK and MT will complete retraining on Record regulations 2380.173 no later than 4/29/2016. Attachments #30, #31 & #32 will show the completion of the training and will be sent upon expected completion. Please see attachments #33, #34, & #35 for dated pictures of individuals #1, #3, & #8. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.173(9)Repeat: Individual #7 ISP review dated 9/18/15 states 1 hour unsupervised time, the ISP states 1/2 hour, and assessment states nothing. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program Specialist (TP) held a meeting with Individual #7 and team members to discuss independence in supervision since the supervision at day program was different than what was for when in the community. The meeting occurred on 4/05/2016 to determine a sufficient supervision level based on the current level of independence for Individual #7 when leaving during program to go into the community. Please see attachment #77. The assessment was updated on 4/08/2016 as a result from what was discussed at the meeting. Please see attachment #78 Track changes were made to the ISP and sent via email to the SCO on 4/08/2016. Please see attachment #79 In order to track independence towards individual #7's supervision, monthly documentation was implemented along with the supervision protocol. Please see attachment #80. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(d)Individual #7's assessment was not dated by the P.S. The program specialist shall sign and date the assessment.Program Specialist (TP) will ensure that all assessments are dated upon completion and review. Individual #7's assessment was reviewed, signed and dated as of 4/11/2016. Please see attachment #25. This assessment has since been updated to reflect other information that has changed related to supervision. This Assessment has also been reviewed, signed and dated as of 4/11/2016. Please see attachment #26. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(9)Individual #7's assessment does not include documentation of disability, including functional and medical limitations. The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.Program Specialist (TP) will ensure that all assessments include documentation of disability, including functional and medical limitations. An addendum was made to individual #7's assessment to address documentation of disability, including functional and medical limitations. This update to the assessment was reviewed, signed and dated as of 4/11/2016. Please see attachment #26. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(10)Individual #4' assessment did not include an updated lifetime medical history. The assessment must include the following information: A lifetime medical history.Program Specialist (AR) updated individual #4's assessment on 4/01/2015 to include the most recent LTMH. Please attachment #27. AR will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #15 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(13)(i)Repeat: Individual #4's assessment did not contain progress over the last 365 calendar days and current level in health. 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.Program Specialist (AR) updated individual #4's assessment on 4/01/2015 to include current level of health and progress over the last 365 calendar days . Please attachment #27. AR will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #15 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(13)(ii)Repeat: Individual #4's assessment did not contain progress over the last 365 calendar days and current level in motor and communication skills. 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.Program Specialist (AR) updated individual #4's assessment on 4/01/2015 to include current level in motor and communication skills and progress over the last 365 calendar days . Please attachment #27. AR will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #15 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(13)(iii)Repeat: Individual #4's assessment did not contain progress over the last 365 calendar days and current level in personal adjustment. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.Program Specialist (AR) updated individual #4's assessment on 4/01/2015 to include current level in personal adjustment and progress over the last 365 calendar days . Please attachment #27. AR will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #15 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(13)(v)Repeat: Individual #7's assessment did not contain progress over the last 365 calendar days and current level in recreation. 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.Program Specialist (TP) created an addendum to individual #7's assessment to address the current level in recreation and progress over the last 365 calendar days. Please see attachment #26. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(13)(vi)Repeat: Individual #7's assessment did not contain progress over the last 365 calendar days and current level in community-integration. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Program Specialist (TP) created an addendum to individual #7's assessment to address the current level in community-integration and progress over the last 365 calendar days. Please see attachment #26. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(e)(14)Individual #8's assessment doesnt state her ability of water safety. The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Program Specialist (MT) created an addendum to individual #8's assessment to address the individual's knowledge of water safety and ability to swim. Please see attachment #27. MT will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #3 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.181(f)Individual #3's assessment was sent on 8/14/15 and ISP was held on 9/2/15.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).Program Specialist (EK) will ensure that assessments are completed and sent to the SCO or plan lead within 30 days prior to the ISP meeting. EK had an ISP meeting for another individual on 3/17/2016. EK completed this individual's assessment on 1/29/2016 and sent to the plan lead. Please see attachments #28 & #29. EK will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #17 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.183(4)Individual #6's ISP has no protocol for unsupervised time. 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.Program Specialist (TP) updated the assessment to address Individual #6's protocol for unsupervised time. Please see attachment # 18. TP also implemented a protocol sheets and community sign out sheet in order to track the individual's progress related to his independence in the community. Please see attachment #19. An email was sent to the individual's supports Coordinator along with track changes to the supervision section to update the ISP. Please see Attachment # 20. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.183(5)Individual #2's ISP did not include a SEEN plan. 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.Program Specialist (MM) will ensure that all SEEN plans are addressed in the ISP. MM made track changes to Individual #2's ISP to address the SEEN plan being added to the ISP along with other updated information. Please see attachment #21. The track changes to the ISP were emailed to the supports coordinator. Please see attachment # 22 A copy of the updated ISP as of 4/01/2016 is also included to reflect the updates to the plan. Please see attachment #23. MM will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #12 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.183(7)(i)Repeat: Individual #6's ISP did not include an assessment of the individual potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.Program Specialist (TP) will ensure that all ISP for the individuals on her caseload will include the potential to advance in vocational programming. TP updated individual #6's ISP to reflect his potential to advance in vocational programming and emailed the changes to the individual's supports coordinator. Please see attachment #24. . TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.183(7)(iii)Repeat; Individual #6's ISP did not include an assessment of the individual potential to advance in competitive community integrated employment. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.Program Specialist (TP) will ensure that all ISP for the individuals on her caseload will include the potential to advance in competitive community-integrated employment. TP updated individual #6's ISP to reflect his potential to advance in competitive community-integrated employment and emailed the changes to the individual's supports coordinator. Please see attachment #24. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.184(a)(1)(iii)Individual #6's ISP meeting did not have a direct service worker in attandance. The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision).A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering a service to the individual.  04/15/2016 Implemented
2380.184(b)Individual #3's ISP meeting did not have at least three plan team members. At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting.Program Specialist (EK) will ensure that there are at least 3 team members other than the individual are present at the ISP meeting. If there are not enough team members present for the meeting, then the meeting will be rescheduled at a later date when enough members can be present. EK had an ISP meeting for another individual on 3/17/2016. This meeting included enough team members present at the meeting. Please see Attachment #16. EK will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #17 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.186(a)Individual #8's ISP review was late. Dated on 6/2/15 and then again on 9/30/15. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Program Specialist (MT) will complete ISP reviews within the required time frame. MT completed Individual #8's most recent ISP review within the required time frame. Please see Attachment #1 & #2. MT will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #3 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.186(b)Individual #8's ISP review dated 5/18/15 was not signed or dated by the individual or P.S. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Correction: Individual #8 is not the correct individual; the correct individual number is individual #6. Individual #6's attendance flocculates depending on his mood. Program specialist (TP) and individual #6 will review, sign and date the ISP review from 5/18/2015 on no later than 4/28/2016 dependant on individual #6's attendance. The ISP review will be sent to team members including family and supports coordinator. Attachments #75 will show the completion of this task and will be sent upon expected completion. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.186(c)(1)Repeat: Individual #7's ISP reviews dated 12/18, 9/18, 6/18, and 3/17 had no progress for independence 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.Program Specialist (TP) will ensure that all ISP reviews address the progress that Individual #7 is making towards his Independence outcome. TP completed Individual #7's most recent ISP review which includes progress with his Independence Outcome. Please see Attachment #6. TP will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #7 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.186(c)(2)Repeat: Individual #1's ISP review dated 1/12/16, 10/12/15, 7/16, and 4/13 did not review the SEEN plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Correction: Individual #1 is not the correct individual, the correct individual number is individual #2. Program Specialist (MM) updated Individual #2's ISP reviews to reflect a review of the SEEN Plan. ISP review 1/12/2016, 10/12/2015, 7/16/2015 & 4/13/2015 were reviewed with individual #2 on 3//10/2016. Please see Attachments #8, #9, #10, & #11. MM will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #12 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
2380.186(e)Individual #4's ISP review dated 9/15/15 did not include option to decline to team members. Needs to state who it was specifically given to. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Program Specialist (AR) sent letters to Individual #4's team members for the option to decline the ISP review on 4/04/2016. Included on the letter is who all the letter was sent to. Please see Attachment #13. Also is a copy of Individual #4's response to the letter that was sent. Please see Attachment #14. AR will complete retraining on Program regulations 2380.181-188 no later than 4/29/2016. Attachment #15 & #4 will show the completion of the training and will be sent upon expected completion. All individual files at the agency will be audited for compliance by designated persons, expected completion date is 10/31/2016. Attachment #5 will show the completion of the individual file audits and will be sent right after expected completion date. 04/29/2016 Implemented
SIN-00068634 Renewal 09/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)A criminal history record check was not completed for Staff #5 within 5 working days of hire. Staff #5 was hired on 6/30/2014. Her criminal record check was not completed until 9/10/2014. An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Staff # 5's PA criminal Background check was ran on 9/10/2014 by HR Manager, Natasha Caruso and provided to licensing that same day. The Agency will ensure that all employees have a PA background check completed prior to or within 5 working days of their hire date. New Employee, Robin Jackson was hire on 9/2/2014; documentation has been provided to show her PA criminal history check was completed on 8/14/2014. Please refer to Attachment #1 for Robin Jackson's PA criminal history check that was completed on 8/14/2014 and Attachment # 2 for Robin Jackson's orientation training for new transportation employee check list that shows date of hire. Orientation training for new habilitation employees check list and orientation training for new transportation employee check list have been updated on 10/09/2014 to reflect the time constraints related to PA criminal history check and FBI criminal history check. There have been no new employees hired since 10/09/2014. Please refer to Attachment # 3 for a copy of the Orientation training for new habilitation employees check list and Attachment #4 for a copy of orientation training for new transportation employee check list HR Manager, Natasha Caruso and CEO, Scott Moore were trained on Regulation 2380.20 Criminal History Record Check on 10/13/2014. Please refer to attachment # 5. 10/13/2014 Implemented
2380.89(g)All individuals in the program did not evacuate during the fire drills held on 4/29/14 and 11/27/13. A second drill was not conducted. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.If all individuals are not able to evacuate the facility within 2 1/2 minutes, the agency will have another fire drill that month. If all individuals still are unable to make it out of the facility within 2 1/2 minutes a plan will need to be implemented to address this situation. The Agency conducted a fire drill on 9/29/2014 by Program Specialist Keshia McGinness. There were a total of 62 individuals in attendance and all 62 individuals were able to evacuate within 1:55.06 minutes. Please refer to Attachment #6 for a copy of the fire drill log and attachment #7 for a copy of the agency roster for the 9/29/2014 fire drill attendance. The Agency conducted another fire drill on 10/13/2014 by Program Specialist Keshia McGinness. There were a total of 75 individuals in attendance including individual #1 and all 75 individuals were able to evacuate within 1:36.98 minutes. Please refer to Attachment #6 for a copy of the fire drill log and attachment #8 for a copy of the agency roster for the 10/13/2014 fire drill attendance. Program Specialist, Meagan Thomas implemented a procedure on 9/26/2014 for Individual # 1 who has not successfully exited the facility during 2 fire drills. This procedure includes training for the individual, the use of a whellchair for transport during a fire drill and a physical assist as a last resort if he does not evacuate. Please see Attachment # 9 for the full procedure. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne, Meagan Thomas and CEO, Scott Moore were trained on Regulations 2380.81-93 Fire Safety on 10/10/2013. Please refer to Attachment #10. 10/13/2014 Implemented
2380.111(a)Individual #2's physical was not completed in the regulatory timeframe. Her past physical was completed on 2/21/13 and not again until 3/10/14. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #2's annual physical was due no later than 3/08/2014 which was a Saturday. Individual #2 did receive her physical on 3/10/2014. Individual #2 was absent from program starting 2/3/2014 and did not return to resume services until 3/11/2014 after her annual physical was obtained by the PCP. Individual #2 was not present at the program at anytime during the lapse in her annual physical dates. Please refer to Attachment #30 for February 2014 Social Rehabilitation Attendance Record, Attachment #31 for February 2014 Haven Cafe Operation Attendance Record, Attachment #32 for March 2014 Social Rehabilitation Attendance Record and Attachment #33 for March 2014 Haven Cafe Operation Attendance Record Attendance record. The agency would like to appeal this citation. The agency will ensure that the individual's record states when services are suspended due to not receiving a current physical within the allotted time frame. A letter will be sent to the individual by the Health Services Coordinator informing them of the suspension in services and a copy will be placed in the file. The individual may resume services after the physical is obtained and all required information is on the physical. Program Specialist will file note when an individual is able to resume services. 10/10/2014 Implemented
2380.111(c)(9)The record for Individual #2 and Individual #9 indicated they each had an allergy. However,there were no allergies documented on the physical for those individual.The physical examination shall include: Allergies or contraindicated medication.Health Services Coordinator, Diana Long LPN contacted Individual #2's Doctor's office on 9/10/2014 and confirmed that she does not have any known allergies. Program Specialist and Plan Lead, Matt McCarrier updated individual #2's face sheet and emergency medical sheet on 9/10/2014 to state that the allergies listed were stated by the individual but not on the physical exam. Please refer to Attachment # 27 for face sheet and Attachment # 28 for emergency medical sheet. Program Specialist and Plan Lead, Matt McCarrier updated individual #2's ISP on 9/10/2014 to also reflect the changes. Please refer to Attachment #29. Health Services Coordinator, Diana Long LPN contacted Individual #9's Doctor's office on 9/10/2014 and confirmed that he does not have any known allergies. The Doctor's offices stated that seasonal allergies is a diagnosis not an allergy, Individual # 9 is not allergic to Aspirin but is to avoid taking aspirin due to being diagnosed with hemophilia, and Red Cross Factor 8 is his diagnosis. Program Specialist, Rashad Payne made updates to his face sheet and emergency medical forms to reflect this information. Please refer to Attachment # 17 for face sheet and Attachment # 18 for emergency medical sheet. Program Specialist, Rashad Payne emailed Individual # 9's Supports Coordinator, Rebecca Smith on 9/10/2014 to update the ISP. Please refer to Attachment #19. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne, Meagan Thomas and Health Services Coordinator, Diana Long LPN were trained on Regulations 2380.111-115 Health Regulations on 10/10/2014. Please refer to Attachment #16. 10/10/2014 Implemented
2380.111(c)(11)REPEAT Individual #2's ISP indicated she should follow a gluten-free, dairy free diet with no nuts. This diet information was not included on the physical. Individual #6's ISP indicates he is to have no caffiene in his diet. This information is not included on the physical. The physical examination shall include: Special instructions for an individual's diet.Health Services Coordinator, Diana Long LPN contacted Individual #2's Doctor's office on 9/10/2014 and confirmed that she does not have any known special diet on record. Program Specialist and Plan Lead, Matt McCarrier updated individual #2's face sheet and emergency medical sheet on 9/10/2014 to state that the special diet listed was stated by the individual but not on the physical exam. Please refer to Attachment # 27 for face sheet and Attachment # 28 for emergency medical sheet. Program Specialist and Plan Lead, Matt McCarrier updated individual #2's ISP on 9/10/2014 to also reflect the changes. Please refer to Attachment #29 for Individual #2's ISP. Program Specialist, Amanda Roupp contacted Individual #6's Residential Provider Supervision, Rose Andrus on 9/10/2014 to look into the matter to see if No Caffeine is still a recommendation for individual #6, the conversation was file noted. Please refer to Attachment #14. The agency received a written statement dated 9/24/2014 from Individual #6's PCP stating that he is not to have Caffeine and is on record in his file along with his annual physical exam. Please refer to Attachment #15. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne, Meagan Thomas and Health Services Coordinator, Diana Long LPN were trained on Regulations 2380.111-115 Health Regulations on 10/10/2014. Please refer to Attachment #16. 10/10/2014 Implemented
2380.173(9)Content Discrepency was located in the record of Individual #4. His physical indicated he was to follow a low fat diet and his ISP indicated he was to follow an 1800 calorie diet. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Program Specialist, Keshia McGinness made updates to his face sheet and emergency medical forms to reflect all diet recommendations. Please refer to Attachment # 22 for face sheet and Attachment # 23 for emergency medical sheet. Program Specialist, Keisha McGinness emailed Individual # 4's Supports Coordinator, Jolene Smith on 10/09/2014 to update the ISP to reflect information related to Terry's Diet. Please refer to Attachment #24. Program Specialist, Keshia McGinness, updated individual #4's Nutrition Plan of support on 9/10/2014, and reviewed by support staff. Please refer to Attachment #25 for nutrition Plan of Support and Attachment #26 for staff's review. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne, Meagan Thomas and Health Services Coordinator, Diana Long LPN were trained on Regulations 2380.171-177 Health Regulations on 10/10/2014. Please refer to Attachment #41. 10/10/2014 Implemented
2380.181(e)(3)(iv)The assessment for Individual #1 did not include progress in personal needs with or without assistance from others. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others.Program Specialist, Meagan Thomas updated Individual #1's assessment on 9/22/2014 to include progress and growth in the area Personal needs with or without assistance from others. Please refer to Attachment #35. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.181(e)(13)(iv)The assessment for Individual #1 did not include his progress over the past 365 days in socialization. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Program Specialist, Meagan Thomas updated Individual #1's assessment on 9/22/2014 to include progress and growth in the area of socialization. Please refer to Attachment #35. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.181(e)(13)(v)REPEAT The assessment for Individual #1 and Individual #3 did not include progress over the past 365 days in recreation.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. Program Specialist, Meagan Thomas updated Individual #1's assessment on 9/22/2014 to include progress and growth in the area of Recreation. Please refer to Attachment #35. Program Specialist, Amanda Roupp updated Individual #3's assessment on 10/09/2014 to include progress and growth in the areas of Recreation. Please refer to Attachment #38. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.181(e)(13)(vi)REPEAT The assessment for Individual #1 and Individual #3 did not include progress over the last 365 days in community integration. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. Program Specialist, Meagan Thomas updated Individual #1's assessment on 9/22/2014 to include progress and growth in the area of Community Integration. Please refer to Attachment #35. Program Specialist, Amanda Roupp updated Individual #3's assessment on 10/09/2014 to include progress and growth in the areas of Community Integration. Please refer to Attachment #38. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.183(5)The ISP for Individual #2 did not include her SEEN plan. 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.Program Specialist and Plan Lead, Matt McCarrier made updates to individual #2's ISP on 9/10/2014 to address that a SEEN Plan is on record at CCCC. Please refer to Attachment #29 for Individual #2's ISP. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.183(7)(i)REPEAT The ISP for Individual #1, #2, #3, #4, #5, #6, and #8 did not include the potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.Program Specialist, Meagan Thomas contacted Individual #1's Supports Coordinator, Brandon Peck, on 10/09/2014 to address adding vocational programming to the ISP. Please refer to Attachment #36. Program Specialist and Plan Lead, Matt McCarrier made updates to individual #2's ISP on 9/10/2014 to better address the potential of advancement in Vocational Programming. Individual #2 also has an outcome of Increasing Independence that also addresses l improving on her vocational skills while at program that was implemented on 7/24/2014. Please refer to Attachment #29 for Individual #2's ISP. Program Specialist, Amanda Roupp contacted Individual #3's Supports Coordinator, Nikki Reese, on 10/09/2014 to address adding vocational programming to the ISP. Please refer to Attachment #39. Program Specialist, Keshia McGinness contacted Individual #4's Supports Coordinator, Jolene Smith, on 10/09/2014 to address adding vocational programming to the ISP. Please refer to Attachment #24. Program Specialist, Tara Pyle contacted Individual #5's Supports Coordinator, Nikki Reese, on 9/10/2014 to address adding vocational programming to the ISP. Please refer to Attachment #21. Program Specialist, Amanda Roupp emailed Individual #6's Support's Coordinator, Samantha Overdorff on 9/10/2014 to address adding vocational programming to the ISP. Please refer to Attachment #13. Program Specialist, Amanda Roupp contacted Individual #8's Supports Coordinator, Lynn Little, on 9/10/2014 to address adding vocational programming to the ISP. Please refer to Attachment #20. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.183(7)(iii)REPEAT The ISP for Individual #1, #2, #3, #4, #5, #6, and #7 did not include the potential to advance in competitive employment. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.Program Specialist, Meagan Thomas contacted Individual #1's Supports Coordinator, Brandon Peck, on 10/09/2014 to address adding competitive employment to the ISP. Please refer to Attachment #36. Program Specialist and Plan Lead, Matt McCarrier made updates to individual #2's ISP on 9/10/2014 to better address the potential of advancement in Competitive Employment. Individual #2 also has an outcome of Increasing Independence that also addresses l improving on her employment skills while at program that was implemented on 7/24/2014. Please refer to Attachment #29 for Individual #2's ISP. Program Specialist, Amanda Roupp contacted Individual #3's Supports Coordinator, Nikki Reese, on 10/09/2014 to address adding competitive employment to the ISP. Please refer to Attachment #39. Program Specialist, Keshia McGinness contacted Individual #4's Supports Coordinator, Jolene Smith, on 10/09/2014 to address adding competitive employment to the ISP. Please refer to Attachment #24. Program Specialist, Tara Pyle contacted Individual #5's Supports Coordinator, Nikki Reese, on 9/10/2014 to address adding competitive employment to the ISP. Please refer to Attachment #21. Program Specialist, Amanda Roupp emailed Individual #6's Support's Coordinator, Samantha Overdorff on 9/10/2014 to address adding competitive employment to the ISP. Please refer to Attachment #13. Program Specialist, Amanda Roupp emailed Individual #7's Support's Coordinator, Ray Lowmiller on 9/10/2014 to address adding competitive employment in the ISP. Please see Attachment # 11. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.186(c)(1)Individual #3 had a goal to participate in group activities three times per week. There was no progress being reported in the ISP reviews for this goal. 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.Program Specialist, Amanda Roupp made a revision to individual #3's quarterly to address progress related to outcomes, this was completed and reviewed on 10/09/2014. Please refer to Attachment #40 for Individual #3's Quarterly Review. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
2380.186(c)(2)The ISP reviews for Individual #1 did not review progress with his SEEN plan. The restrictive measures and when they are being used were not being reviewed.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Specialist, Meagan Thomas made a revision to individual #1's quarterly to address review of targeted behaviors, this was completed and reviewed on 10/09/2014. Please refer to Attachment #37 for Individual #1's Quarterly Review. Program Specialists, Amanda Roupp, Keshia McGinness, Tara Pyle, Matt McCarrier, Rashad Payne and Meagan Thomas were trained on Regulations 2380.181-188 Program Regulations on 10/10/2014. Please refer to Attachment #12. 10/10/2014 Implemented
SIN-00055215 Renewal 09/23/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The documentation for the fire drills conducted on 11/6/12 and 6/11/13 did not include the amount of time it took individuals to evacuate. (c)  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.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The responsibility of time tracking during fire drills and false alarms will be distributed to 2 agency employees on the Management team. During a planned fire drill, one of these employees will use the official stopwatch, while the second uses a watch or clock. Clocks are available in all program areas and offices. In the case of an unexpected alarm, these staff will check time immediately upon the sounding of the alarm and check time again after ensuring the safe evacuation of all participants and staff. These designated staff will be responsible for recording these times on the fire drill record. The Agency will no longer be using false alarms as fire drills. In the case of a false alarm, the time will be documented as part of the incident report. The incident report for the false alarm will be kept on file in a separate section of the fire manual. During the month of the false alarm, a fire drill will still be executed and documented appropriately. This information was addressed at management meeting on 11/7/13, and a policy was implemented on 11/12/13. Reference Attach A. 11/12/2013 Implemented
2380.111(c)(5)The TB test for Individual #5 was completed late. It was done on 5/22/12, but then not again until 6/12/13.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The Agency will continue to send out 4 notifications for TB test. Notifications state the need and the dates by which documentation is necessary. If documentation of the TB test is not obtained by the due date, services will be discontinued until the date that necessary information is obtained. Agency director or designee will contact the individual/family/guardian/caregiver by phone notifying them of the discontinuation of services. A file note will be placed in the individual's record in regards to the issue to include: copies of initial notification letters sent; date services were discontinued; date documentation was received; and date services resumed. Reference Attach B and Attach C. 11/07/2013 Implemented
2380.111(c)(6)The physical examination form for Individual #6, dated 12/4/12, did not include if she was free from communicable diseases. (c)  The physical examination shall include:(6)  Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 All physical exam forms received by the Agency will be reviewed by a designated person to ensure the accuracy of required documentation. A checklist has been implemented based upon regulation 2380.111. Any form missing required documentation will be returned in order to be corrected/completed by physician. Reference Attach D. 11/07/2013 Implemented
2380.111(c)(11)The physical examination form for Individual #6, dated 12/4/12, did not include a diet section. (c)  The physical examination shall include:(11)  Special instructions for an individual's diet.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 All physical exam forms received by the Agency will be reviewed by a designated person to ensure the accuracy of required documentation. A checklist has been implemented based upon regulation 2380.111. If special instructions or other information is accompanying a physical exam form, the attached information/forms must also contain a physician's signature. Any form missing required documentation will be returned in order to be corrected/completed by physician. Reference Attach D. 11/07/2013 Implemented
2380.113(a)The physical for Staff #1 was completed late. It was done on 4/19/10, but then now again until 8/13/12.(a)  A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The Agency will continue to send out 3 notifications for physical exam/TB. Notifications state the need and the dates by which documentation is necessary. If documentation of the physical is not obtained by the due date, the staff member will be suspended without pay until proper documentation is received. A file note will be placed in the staff's personnel file in regards to the issue to include: copies of initial notification letters sent; date of suspension; date documentation was received; and date returned to normal work status. Reference Attach E and Attach F. 11/07/2013 Implemented
2380.113(c)(2)The TB test was completed late for Staff #1. It was done on 4/19/10, but then not again until 8/13/12.(c)  The physical examination shall include:(2)  Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The Agency will continue to send out 3 notifications for physical exam/TB. Notifications state the need and the dates by which documentation is necessary. If documentation of the physical/TB is not obtained by the due date, the staff member will be suspended without pay until proper documentation is received. A file note will be placed in the staff's personnel file in regards to the issue to include: copies of initial notification letters sent; date of suspension; date documentation was received; and date returned to normal work status. Reference Attach E and Attach F. 11/07/2013 Implemented
2380.122aThe Diastat medication label for Individual #7 did not include a specific dosage. It only said to take for prolonged seizures. It did not indicate a specific time of when it was to be administered and how many dosages can be given in a period of time. On 11/29/12, Diastat was administered 3 times to Individual #7. REPEAT VIOLATION FROM INSPECTION CONDUCTED ON 9/18/2013. Prescriptions for medications may be written by a certified registered nurse practitioner as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners). The label on the original container must include the name of the prescribing practitioner.Staff training was conducted March 31, 2014 regarding intake of medications into the facility. Also, a plan was put into place March 31, 2014 regarding intake of medications into the facility. (attachment 13 Also, an addition was added to the 5 checks for receiving medication into the facility (attachment 11) See email dated 6/10/14 for attachments. 11/07/2013 Implemented
2380.173(7)The current ISP for Individual #6 was not available in her record. (7)  A copy of the current ISP.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 This record was reviewed during Management meeting on 11/7/13. As of this review, the ISP document was present in file. The attached staff review form shows that the ISP was reviewed by program staff on 9/6/13. The agency has developed a detailed intake process in order to ensure that the initial ISP is placed in file upon admission to the program. The assigned program specialist will be responsible for assuring that a current ISP is always in the record. A quality manager position has been created; to be effective January 2014. The quality manager is responsible for checking individual files on a monthly basis to ensure that documents are current. The quality manager is developing a program specialist training and accompanying manual/tool in order to assist all program specialists in fully understanding and working within 2380 regulations. Training dates have been scheduled for 11/15/2013 and 11/19/2013. Reference Attach G. 11/07/2013 Implemented
2380.173(9)According to the ISP for Individual #5, there is no behavioral plan of support in place; however, Individual #5 does have a behavioral plan of support. (9)  Content discrepancies in the ISP, the annual update or revision under §  2380.186.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 Updates were made to Individual #5 ISP. Individual #5 complete file was reviewed during management meeting on 11/7/2013. As of this review, revised ISP was in file. The ISP was again reviewed by staff on 11/14/13 as the content of the ISP had changed to include this and other information. A quality manager position has been created; to be effective January 2014. The quality manager is responsible for checking individual files on a monthly basis to ensure that documents are current. ISP and Quarterly Review content information will be included in the program specialist manual currently in development by quality manager. Reference Attach H and Attach J . 11/14/2013 Implemented
2380.181(a)The Initial Assessment for Individual #6 was not completed. Her admissions date was 5/7/13.(a)  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.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 Individual #6 record was reviewed during Management meeting on 11/7/13. The assessment was present in the file at this review. The assessment was completed and signed by Program Specialist and Individual on 8/6/13. A quality manager position has been created; to be effective January 2014. The Quality Manager will be responsible for monthly record reviews in order to ensure that records are current and complete. Monthly reviews will be ongoing. Quality Manager will coordinate with Program Specialist as needed for documentation. Reference Attach K. 11/07/2013 Implemented
2380.181(e)(3)(i)The assessments completed for Individual #3 and Individual #5 did not include progress in acquisition of functional skills, communication, personal adjustment and needs with / without assistance. (e)  The assessment must include the following information: (3)  The individual's current level of performance and progress in the following areas:(i)   Acquisition of functional skills. (ii) Communication (iii) Personal Adjustment (iv) Needs with / without assistancePARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The Assessments for Individuals #3 and #5 were revised to include progress and growth information. Individual #3 Assessment was revised and reviewed on 11/11/2013; Individual #5 Assessment was revised and reviewed on 11/11/13. The Agency Assessment form has been revised in order to more accurately address progress and growth in all areas noted. A quality manager position has been created; to be effective January 2014. The Quality Manager will be responsible for reviewing Individual files on a monthly basis. Quality Manager will ensure that records are current and content is complete. Reference Attach L; Attach M; and Attach N. 11/11/2013 Implemented
2380.181(e)(13)(i)The assessments for Individual #3 and Individual #5 did not include progress and growth in the following areas: Health, Motor/Communication Skills, Personal Adjustment, Socialization, Recreation and Community Integration. Also, the assessment for Individual #6 did not include current level in socialization, recreation and community integration. (e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (i)   Health (ii) Motor/Communication Skills (iii) Personal Adjustment (iv) Socialization (v) Recreation (vi) Community Integration PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The Assessments for Individuals #3 and #5 were revised to include progress and growth information. Individual #3 Assessment was revised and reviewed on 11/11/2013; Individual #5 Assessment was revised and reviewed on 11/11/13. Individual #6 Initial Assessment is present in file with complete information. Progress and Growth for Individual #6 will be noted for all areas as new, revised assessment template will be used for all future agency assessments. The Agency Assessment form has been revised in order to more accurately address progress and growth in all areas noted. A quality manager position has been created; to be effective January 2014. The Quality Manager will be responsible for reviewing Individual files on a monthly basis. Quality Manager will ensure that records are current and content is complete. Reference Attach L; Attach M; Attach K; and Attach N. 11/11/2013 Implemented
2380.183(2)The ISP for Individual #6 did not include services to increase community involvement. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: (2)  Services provided to the individual to increase community involvement, including work opportunities as required under §  2380.188 (relating to provider services).PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The ISP for Individual #6 has been updated to include community involvement information. SC was contacted by program specialist to request changes on 11/13/13. Staff reviewed new ISP content on 11/14/13. A quality manager position has been created; to be effective January 2014. The Quality Manager will be responsible for reviewing Individual files on a monthly basis. Quality Manager will ensure that records are current and content is complete. Reference Attach O and Attach P. 11/14/2013 Implemented
2380.183(7)(i)The ISP for Individual #5 does not include his potential to advance in vocational programming and competitive community employment. The ISP for Individual #6 does not include her potential to advance in vocational programming, competitive community employment and community involvement. Also, the ISP for Individual #3 does not address his potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: (7)  Assessment of the individual's potential to advance in the following:(i)   Vocational programming (iii) Community Involvement (iii) Vocational Programming (iv) Competitive Community-Integrated Employment.PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 12/24/13 The ISP for Individual #5 has been updated to include all information. SC was contacted by Program Specialist to input changes on 11/4/13. ISP was completed as of 11/14/13. Individual #5 ISP was printed, new content reviewed by staff, and filed on 11/14/13. The ISP for Individual #3 has been updated. SC was contacted by Program Specialist on 11/13/13. ISP was completed as of 11/14/13. Individual #3 ISP was printed, new content reviewed by staff, and filed on 11/14/13. The ISP for Individual #6 has been updated to include all information. SC was contacted by Program Specialist to input changes on 11/13/13. ISP was completed as of 11/14/13. Individual #6 ISP was printed, new content reviewed by staff, and filed on 11/14/13. A quality manager position has been created; to be effective January 2014. The Quality Manager will be responsible for reviewing Individual files on a monthly basis. Quality Manager will ensure that records are current and content is complete. Reference the following attachments: Attach H; Attach J; Attach O; Attach P; Attach Q; Attach R. 11/14/2013 Implemented
SIN-00191563 Renewal 08/18/2021 Compliant - Finalized