| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(1) | Individual 1's current physical dated 1/25/24 did not include a review of medical history. The section on the form was left blank. | The physical examination shall include: A review of previous medical history. | The individual and family was sent a letter explaining the need for the medical history section on the physical form to be completed. Once we receive the completed form we will submit it to the licensing team. |
10/18/2024
| Implemented |
| 2380.111(c)(6) | Individual 1's current physical dated 1/25/24 did not indicate whether or not the individual was free of communicable disease. | 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. | The individual and family was sent a letter explaining the need for the medical history section on the physical form to be completed. Once we receive the completed form we will submit it to the licensing team. |
10/18/2024
| Implemented |
| 2380.111(c)(7) | Individual 2's physical exam did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 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. | The individual and family was sent a letter explaining the need for all sections on the physical form to be completed. Once we receive the completed form we will submit it to the licensing team. |
10/18/2024
| Implemented |
| 2380.111(c)(11) | Individual 2's physical exam did not include special instructions for an individual's diet. | The physical examination shall include: Special instructions for an individual's diet. | Individual's diet information has been added to the physical form. |
10/18/2024
| Implemented |
| 2380.113(a) | There was no physical examination done for staff member 3 in the past 2 years. | 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. | Staff member 3 has an appointment scheduled for a complete physical on 10/25/2024. |
10/18/2024
| Implemented |
| 2380.113(c)(4) | Staff member 2's physical exam did not include information of medical problems which might interfere with the safety or health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals. | Schedule and plan for correcting staff #2 physical:
CATCH employee added necessary information on his physical to state if there were any pertinent medical problem which might interfere with the safety or health of an individual.
CATCH added a sentence on the physical form that specifically states information must include any medical problem that might interfere with the safety or health of the individual.
Assessment of current physicals:
Upon review of staff physicals all forms included information completed by the physician that indicated if there were any medical problems which might interfere with the safety or health of individuals. |
10/18/2024
| Implemented |
| 2380.181(a) | Individual 2 had an annual assessment done on 12/12/23 and the one done prior to that was on 09/17/22. | 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. | Individual assessment is currently up to date. |
10/18/2024
| Implemented |
| 2380.39(c)(1) | Staff person 1's annual training did not include the topic of: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff member 1 has completed the missing required training on the following topics: application of person centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.
All staff have completed the missed required trainings and the training tracker has been updated. Upon review of the training trackers, Program Manager and ID Director learned that when a new training curriculum was developed in 2023, some required trainings were left off the tracker which caused the deficiency in our trainings. The tracker has been updated and reviewed for accuracy to prevent training deficiencies in the future. |
10/18/2024
| Implemented |
| 2380.39(c)(2) | Staff person 1's annual training did not include: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff member 1 has completed the missing required training on the following topics: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Adult Protective Services Act and applicable protective services regulations.
All staff have completed the missed required trainings and the training tracker has been updated. Upon review of the training trackers, Program Manager and ID Director learned that when a new training curriculum was developed in 2023, some required trainings were left off the tracker which caused the deficiency in our trainings. The tracker has been updated and reviewed for accuracy to prevent training deficiencies in the future. |
10/18/2024
| Implemented |
| 2380.39(c)(3) | Staff person 1's annual training did not include the topic of: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff member 1 has completed the missing required training on the following topics: Individual rights.
All staff have completed the missed required trainings and the training tracker has been updated. Upon review of the training trackers, Program Manager and ID Director learned that when a new training curriculum was developed in 2023, some required trainings were left off the tracker which caused the deficiency in our trainings. The tracker has been updated and reviewed for accuracy to prevent training deficiencies in the future. |
10/18/2024
| Implemented |
| 2380.39(c)(5) | Staff member 2 and 3's annual training did not include the topic: safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff member 2 and 3 have completed the missing required training on the following topic: safe and appropriate use of behavior supports, Reinforcement strategy.
All staff have completed the missed required trainings and the training tracker has been updated. Upon review of the training trackers, Program Manager and ID Director learned that when a new training curriculum was developed in 2023, some required trainings were left off the tracker which caused the deficiency in our trainings. The tracker has been updated and reviewed for accuracy to prevent training deficiencies in the future. |
10/18/2024
| Implemented |