| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.33(b)(10) | The program specialist for Individual #1 did not review, sign, and date the September 2015 monthly documentation of the individual's participation and progress toward outcomes. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of a client's participation and progress toward outcomes. | The floor supervisor in question is missing documentation of her GED in her file. The floor supervisor abandoned the documentation when she fled from a dangerous domestic situation. Lark suspended her initially from all work without pay until a copy of the necessary paperwork could be retrieved from the Commonwealth of Pennsylvania. Copies of GED completion are held at the state level and the request for the copy will take approximately 10 to 14 business days according to the relevant state agency (Pennsylvania Department of Education). The floor supervisor in question will not return to client services until the necessary paperwork arrives at our offices. In the meantime we have decided to allow the individual to work in our Administrative Offices where she has no contact with clients. This decision was made as a result of our belief in her honesty surrounding the situation and our desire not to place her and her child in greater financial hardship. The capacity we have her working in does not possess the aforementioned criteria for employment. [As per conversation Adm. Service Director on 12/8/15, the following POC was to be submitted, the one above was mistakenly entered in. The timeline for documentation, as found in Lark¿s Provision of Services Policy and Procedures, will be strictly adhered to from this point forward. The program specialists will be retrained on the Provision of Services Policy and Procedures by November 25, 2015. The check sheet for monitoring the ISP/review process will be utilized to ensure compliance on the part of the program specialists. Additionally, Lark has entered into a record review process in order to find and correct deficiencies in client files. This process of spot-checking occurs every three months on randomly selected client files. This allows us to find patterns in our processes that need to be addressed and rectified for continuing compliance. The information generated through this process serves as the foundation for analyzing policies and procedures for possible clarification or change. Implementation of policies and procedures is also reviewed through this process to ensure fidelity to state and federal regulations. The discovered patterns will also allow us to see deficits in implementation for staff retraining. This process is another tool to ensure the above situation does not occur moving forward. An outcome goal is contained within Lark¿s Quality Management Plan that addresses this area for possible deficiency and is a part of the record review recording form. Rehab director retrained PS on 11/25/15. (AS 12/8/15)] |
11/23/2015
| Implemented |
| 2390.35(d) | Floor supervisor #1 hired 8/15/15 did not possess 30 credit hours from an accredited college or university, or a high school diploma or a general education development certificate. | A floor supervisor shall meet one of the following qualifications: (1) Possess 30 credit hours from an accredited college or university.(2) Possess a high school diploma or a general education development certificate, and 1 year work experience in industry or rehabilitation. | The floor supervisor in question is missing documentation of her GED in her file. The floor supervisor abandoned the documentation when she fled from a dangerous domestic situation. Lark suspended her initially from all work without pay until a copy of the necessary paperwork could be retrieved from the Commonwealth of Pennsylvania. Copies of GED completion are held at the state level and the request for the copy will take approximately 10 to 14 business days according to the relevant state agency (Pennsylvania Department of Education). The floor supervisor in question will not return to client services until the necessary paperwork arrives at our offices. In the meantime we have decided to allow the individual to work in our Administrative Offices where she has no contact with clients. This decision was made as a result of our belief in her honesty surrounding the situation and our desire not to place her and her child in greater financial hardship. The capacity we have her working in does not possess the aforementioned criteria for employment. [CEO or designee will immediately review all personnel files to ensure staff have the required qualifications for respective positions and documentation will be maintained in personnel files for review by the department. Documentation of qualifications for floor supervisor #1 will be submitted upon receipt to the department via email to ascharpf@pa.gov. (AS 12/4/15)] |
11/23/2015
| Implemented |
| 2390.124(9)(ii) | The record for Individual #2 did not include a copy of the signature sheet for the annual update meeting held on 3/24/15. | Each client's record must include the following information: A copy of the signature sheet for: The annual update meeting. | The signature sheet will be generated and signed to be entered into the record by November 25, 2015. Additionally, Lark has entered into a record review process in order to find and correct deficiencies in client files. This process of spot-checking occurs every three months on randomly selected client files. This allows us to find patterns in our processes that need to be addressed and rectified for continuing compliance. The information generated through this process serves as the foundation for analyzing policies and procedures for possible clarification or change. Implementation of policies and procedures is also reviewed through this process to ensure fidelity to state and federal regulations. The discovered patterns will also allow us to see deficits in implementation for staff retraining. This process is another tool to ensure the above situation does not occur moving forward. An outcome goal is contained within Lark¿s Quality Management Plan that addresses this area for possible deficiency and is a part of the record review recording form. A checklist is also utilized to ensure all records meet with state and federal regulations. |
11/23/2015
| Implemented |
| 2390.156(a) | The most recent ISP review of the services and expected outcomes in the ISP for Individual #2 was completed on 6/23/15. | 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP. | The timeline for documentation, as found in Lark¿s Provision of Services Policy and Procedures, will be strictly adhered to from this point forward. The program specialists will be retrained on the Provision of Services Policy and Procedures by November 25, 2015. The check sheet for monitoring the ISP/review process will be utilized to ensure compliance on the part of the program specialists. Additionally, Lark has entered into a record review process in order to find and correct deficiencies in client files. This process of spot-checking occurs every three months on randomly selected client files. This allows us to find patterns in our processes that need to be addressed and rectified for continuing compliance. The information generated through this process serves as the foundation for analyzing policies and procedures for possible clarification or change. Implementation of policies and procedures is also reviewed through this process to ensure fidelity to state and federal regulations. The discovered patterns will also allow us to see deficits in implementation for staff retraining. This process is another tool to ensure the above situation does not occur moving forward. An outcome goal is contained within Lark¿s Quality Management Plan that addresses this area for possible deficiency and is a part of the record review recording form. |
11/23/2015
| Implemented |
| 2390.156(d) | The following ISP review documentation for Individual #2 was not sent to the SC and plan team members within 30 calendar days after the ISP review meeting: 3/31/15 to 6/23/15 sent 8/25/15; 12/11/14 to 3/31/15 sent 5/1/15.
The following review documentation for Individual #3 was not sent to the SC and plan team members within 30 calendar days after the ISP review meeting: 3/2/15 to 6/16/15 sent 8/20/15; and 6/16/15 to 9/25/15 sent 11/3/15.
The following review documentation for Individual #4 was not sent to the SC and plan team members within 30 calendar days after the ISP review meeting: 6/24/15 to 9/29/15 sent 11/4/15; 3/19/15 to 6/24/15 sent 8/20/15; and 12/15/14 to 3/19/15 sent 4/30/15.
The following ISP review documentation for Individual #5 was not sent to the SC and plan team within 30 calendar days after the ISP review meeting: 6/9/15 to 9/22/15 sent 11/21/15; 3/5/15 to 6/9/15 sent 8/11/15; 12/4/14 to 3/5/15 sent 4/24/15; and 9/8/14 to 12/4/14 sent 1/5/15.
The following ISP review documentation for Individual #6 was not sent to the SC and plan team members within 30 calendar days after the ISP review meeting: 6/5/15 to 9/21/15 sent 11/4/15; 3/6/15 to 6/5/15 sent 8/10/15; 12/5/15 to 3/6/15 sent 4/27/15; and 9/2/14 to 12/5/14 sent 1/12/15. | The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The timeline for documentation, as found in Lark¿s Provision of Services Policy and Procedures, will be strictly adhered to from this point forward. The program specialists will be retrained on the Provision of Services Policy and Procedures by November 25, 2015. The check sheet for monitoring the ISP/review process will be utilized to ensure compliance on the part of the program specialists. Additionally, Lark has entered into a record review process in order to find and correct deficiencies in client files. This process of spot-checking occurs every three months on randomly selected client files. This allows us to find patterns in our processes that need to be addressed and rectified for continuing compliance. The information generated through this process serves as the foundation for analyzing policies and procedures for possible clarification or change. Implementation of policies and procedures is also reviewed through this process to ensure fidelity to state and federal regulations. The discovered patterns will also allow us to see deficits in implementation for staff retraining. This process is another tool to ensure the above situation does not occur moving forward. An outcome goal is contained within Lark¿s Quality Management Plan that addresses this area for possible deficiency and is a part of the record review recording form. |
11/23/2015
| Implemented |