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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(7) | The physical examination dated 4/20/16 for Individual #1 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section 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. | ¿ ¿ On Friday, October 27, 2016, Alli Mitchell, Assistant Program Director contacted (via email) the residential program specialist to request that this information that was left blank be completed by the medical provider. The Assistant Program Director also provided a copy of the VTDC Physical form.
¿ The completed form will be submitted upon receipt.
¿ The Assistant Program Director will ensure all individual records on the Crossing Bridges caseload are evaluated for compliance and include all required medical information by 11/07/16.
¿ The APD will also note the day they were evaluated, who evaluated them for compliance, and the mechanism used (i.e. VTDC site visit checklist and ATF licensure checklist).
¿ The Assistant Program Director will follow-up, as needed, to ensure that any discoveries are corrected and submitted upon receipt.
¿ The Program Quality/Training Coordinator will continue to monitor the individual¿s records for compliance on a monthly basis. All observations or discoveries made during monthly site visits are documented on a ¿VTDC Site Visit Summary form¿ and discussed with the Program Specialist. The Program Specialist signs-off on a ¿Site Visit Staff Signature Sheet¿ to acknowledge that all topics were reviewed.
On June 8, 2016, the Compliance/Quality Director and Program Quality Training Coordinator made modifications to the VTDC Medical Examination form to include a Notice at the beginning and Reminder at the end of the form, which states, ¿The Medical Examination form must be completed in its entirety, with all responses completed, in order to meet regulatory requirements for participation in a VTDC program licensed by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.¿ The form was distributed via email by the Program Quality Training Coordinator to the Program Director and Program Specialists responsible for distributing and collecting Medical Examinations forms for Intake and annually thereafter.
The Program Specialist is responsible to review participant physicals for completeness at intake using the attached VTDC [Participant] Orientation Checklist. The Program Specialist is also responsible to review the participant physical for completeness at the time of renewal. To ensure physicals are completed in their entirety as a requirement for participation in the program, on June 30, 2016, the Program Quality Training Coordinator updated the corresponding section of the VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual with a notation, which states: ¿[A participant] may not attend ATF until you receive the physical form completed in its entirety!¿ (The VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual is used as a reference tool, in addition to regular training on regulations, policies, and procedures, to assist Program Specialists during their training of Program Specialist duties).
On June 30, 2016, Mary Kush, the Program Quality Training Coordinator reviewed the updated VTDC Participant Physical Form and Procedure for Participant Physicals and the corresponding updated section of the VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual with the Program Director. [On 10/18/16, Individual #1's physical examination was returned to physician for completion. For at least 1 year the Program Quality Training Coordinator (along with the program specialist) shall review all completed individuals' physical examinations to ensure all required information is present and there are not required areas left blank. Documentation of all reviews shall be kept. (AS 12/6/16) |
10/30/2016
| Implemented |
| 2380.111(c)(8) | The physical examination dated 4/20/16 for Individual #1 did not include physical limitations. This section was left blank. | The physical examination shall include: Physical limitations of the individual. | ¿ ¿ On Friday, October 27, 2016, Alli Mitchell, Assistant Program Director contacted (via email) the residential program specialist to request that this information that was left blank be completed by the medical provider. The Assistant Program Director also provided a copy of the VTDC Physical form.
¿ The completed form will be submitted upon receipt.
¿ The Assistant Program Director will ensure all individual records on the Crossing Bridges caseload are evaluated for compliance and include all required medical information by 11/07/16.
¿ The APD will also note the day they were evaluated, who evaluated them for compliance, and the mechanism used (i.e. VTDC site visit checklist and ATF licensure checklist).
¿ The Assistant Program Director will follow-up, as needed, to ensure that any discoveries are corrected and submitted upon receipt.
¿ The Program Quality/Training Coordinator will continue to monitor the individual¿s records for compliance on a monthly basis. All observations or discoveries made during monthly site visits are documented on a ¿VTDC Site Visit Summary form¿ and discussed with the Program Specialist. The Program Specialist signs-off on a ¿Site Visit Staff Signature Sheet¿ to acknowledge that all topics were reviewed.
On June 8, 2016, the Compliance/Quality Director and Program Quality Training Coordinator made modifications to the VTDC Medical Examination form to include a Notice at the beginning and Reminder at the end of the form, which states, ¿The Medical Examination form must be completed in its entirety, with all responses completed, in order to meet regulatory requirements for participation in a VTDC program licensed by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.¿ The form was distributed via email by the Program Quality Training Coordinator to the Program Director and Program Specialists responsible for distributing and collecting Medical Examinations forms for Intake and annually thereafter.
The Program Specialist is responsible to review participant physicals for completeness at intake using the attached VTDC [Participant] Orientation Checklist. The Program Specialist is also responsible to review the participant physical for completeness at the time of renewal. To ensure physicals are completed in their entirety as a requirement for participation in the program, on June 30, 2016, the Program Quality Training Coordinator updated the corresponding section of the VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual with a notation, which states: ¿[A participant] may not attend ATF until you receive the physical form completed in its entirety!¿ (The VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual is used as a reference tool, in addition to regular training on regulations, policies, and procedures, to assist Program Specialists during their training of Program Specialist duties).
On June 30, 2016, Mary Kush, the Program Quality Training Coordinator reviewed the updated VTDC Participant Physical Form and Procedure for Participant Physicals and the corresponding updated section of the VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual with the Program Director.[On 10/18/16, Individual #1's physical examination was returned to physician for completion. For at least 1 year the Program Quality Training Coordinator (along with the program specialist) shall review all completed individuals' physical examinations to ensure all required information is present and there are not required areas left blank. Documentation of all reviews shall be kept. (AS 12/6/16) |
10/30/2016
| Implemented |
| 2380.111(c)(10) | The physical examination for Individual #1 dated 4/20/16 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | ¿ ¿ On Friday, October 27, 2016, Alli Mitchell, Assistant Program Director contacted (via email) the residential program specialist to request that this information that was left blank be completed by the medical provider. The Assistant Program Director also provided a copy of the VTDC Physical form.
¿ The completed form will be submitted upon receipt.
¿ The Assistant Program Director will ensure all individual records on the Crossing Bridges caseload are evaluated for compliance and include all required medical information by 11/07/16.
¿ The APD will also note the day they were evaluated, who evaluated them for compliance, and the mechanism used (i.e. VTDC site visit checklist and ATF licensure checklist).
¿ The Assistant Program Director will follow-up, as needed, to ensure that any discoveries are corrected and submitted upon receipt.
¿ The Program Quality/Training Coordinator will continue to monitor the individual¿s records for compliance on a monthly basis. All observations or discoveries made during monthly site visits are documented on a ¿VTDC Site Visit Summary form¿ and discussed with the Program Specialist. The Program Specialist signs-off on a ¿Site Visit Staff Signature Sheet¿ to acknowledge that all topics were reviewed.
On June 8, 2016, the Compliance/Quality Director and Program Quality Training Coordinator made modifications to the VTDC Medical Examination form to include a Notice at the beginning and Reminder at the end of the form, which states, ¿The Medical Examination form must be completed in its entirety, with all responses completed, in order to meet regulatory requirements for participation in a VTDC program licensed by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.¿ The form was distributed via email by the Program Quality Training Coordinator to the Program Director and Program Specialists responsible for distributing and collecting Medical Examinations forms for Intake and annually thereafter.
The Program Specialist is responsible to review participant physicals for completeness at intake using the attached VTDC [Participant] Orientation Checklist. The Program Specialist is also responsible to review the participant physical for completeness at the time of renewal. To ensure physicals are completed in their entirety as a requirement for participation in the program, on June 30, 2016, the Program Quality Training Coordinator updated the corresponding section of the VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual with a notation, which states: ¿[A participant] may not attend ATF until you receive the physical form completed in its entirety!¿ (The VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual is used as a reference tool, in addition to regular training on regulations, policies, and procedures, to assist Program Specialists during their training of Program Specialist duties).
On June 30, 2016, Mary Kush, the Program Quality Training Coordinator reviewed the updated VTDC Participant Physical Form and Procedure for Participant Physicals and the corresponding updated section of the VTDC ATF ¿ Program Specialist Responsibilities/Duties Reference Manual with the Program Director.[On 10/18/16, Individual #1's physical examination was returned to physician for completion. For at least 1 year the Program Quality Training Coordinator (along with the program specialist) shall review all completed individuals' physical examinations to ensure all required information is present and there are not required areas left blank. Documentation of all reviews shall be kept. (AS 12/6/16) |
10/30/2016
| Implemented |
| 2380.173(1)(ii) | The record for Individual #2 did not include identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | ¿ The Assistant Program Director will ensure all individual records on the Crossing Bridges caseload are evaluated for compliance and include all required personal information by 11/07/16.
¿ The APD will also note the day they were evaluated, who evaluated them for compliance, and the mechanism used (i.e. VTDC site visit checklist and ATF licensure checklist).
¿ The Assistant Program Director will follow-up, as needed, to ensure that any discoveries are corrected by 11/14/2016.
¿ The Program Quality/Training Coordinator will continue to monitor the individual¿s records for compliance on a monthly basis. All observations or discoveries made during monthly site visits are documented on a ¿VTDC Site Visit Summary form¿ and discussed with the Program Specialist. The Program Specialist signs-off on a ¿Site Visit Staff Signature Sheet¿ to acknowledge that all topics were reviewed.To ensure individual records include all required personal information, VTDC¿s Face Sheet, which is part of the participant Intake Packet, was modified on 10/27/2016 to delineate between participants in a licensed Adult Training Facility and a licensed 2390. In this instance, Individual #2 had transferred from a licensed 2390 to a licensed 2380 and the face sheet was not updated. See attached.[Individual #2's record was updated to include "N/A" for identifying marks on 11/9/16. (AS 12/6/16)] |
10/30/2016
| Implemented |
| 2380.181(f) | The program specialist did not provide the assessment dated 11/15/15 for Individual #1 to all plan team members including the residential provider. | 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). | ¿ The Assistant Program Director will ensure all assessments on the Crossing Bridges caseload are evaluated for compliance by 11/07/16.
¿ The APD will also note the day they were evaluated, who evaluated them for compliance, and the mechanism used (i.e. VTDC site visit checklist and ATF licensure checklist).
¿ The Assistant Program Director will follow-up, as needed, to ensure that any discoveries are corrected.
¿ The Program Quality/Training Coordinator will continue to monitor the assessments for compliance on a monthly basis. All observations or discoveries made during monthly site visits are documented on a ¿VTDC Site Visit Summary form¿ and discussed with the Program Specialist. The Program Specialist signs-off on a ¿Site Visit Staff Signature Sheet¿ to acknowledge that all topics were reviewed.
To ensure assessments are completed and submitted to the Supports Coordinator within the required timeframe, on June 30, 2016, the Program Quality Training Coordinator updated the Caseload Chart section of the Venango Training and Development Center Adult Training Facility Program Specialist Responsibilities/Duties Reference Manual, which is used as a reference tool, in addition to regular training on regulations, policies, and procedures, to assist Program Specialists during their training of Program Specialist duties.
The Caseload section was updated include and describe how the Caseload Chart excel database is used by the Program Specialists and Program Quality Training Coordinator to monitor due dates and participant information, as well as, plan Monthly site visits. Revisions to this section also include a bolded notation to remind Program Specialists to update the chart ¿every two weeks.¿
On June 8, 2016, the ¿VTDC Caseload Chart¿ spreadsheet was formatted with a condition to return a highlight when an Assessment due date occurs within the next 45 days. This alert will be utilized by the Program Training Coordinator, effective June 9, 2016, during monthly site visits, as an additional internal control to alert Program Specialists, which and when Assessments are due. The Caseload Chart is updated monthly by the Program Specialist and monitored monthly by the Program Director.[Immediately and at least quarterly for 1 year the Quality/training Coordinator at will review the correspondence documentation of assessments being sent to ensure the program specialist(s) are providing the assessment to all plan team members as required. Documentation of the reviews shall be kept. (12/6/16)] |
10/30/2016
| Implemented |
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