| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00254124
|
Renewal
|
10/22/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | At 11:59AM on 10/23/2024, a bottle of Pine Glo Disinfectant and a bottle of Breakthru Drain Cleaner were unlocked and accessible in the cabinet under the sink in the kitchen on the first floor of the facility. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | On 10/23/2024 the Director immediately removed poisonous materials from the cabinet under the sink in the kitchen on the first floor of the facility. |
11/07/2024
| Implemented |
| 2380.53(b) | At 12:13PM on 10/23/2024, an unlabeled, plastic spray bottle containing an unknown, pink liquid substance was in the cabinet under the sink in the bathroom on the lower level of the facility. | Poisonous materials shall be stored in their original, labeled containers. | On 10/23/2024 the Director immediately removed the unlabeled, plastic spray bottle containing the unknown pink liquid substance and discarded. |
11/07/2024
| Implemented |
| 2380.58(a) | At 12:03PM on 10/23/2024, there were two circular holes approximately two inches in diameter on the floor of the bathroom closest to the kitchen on the first floor of the facility. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 10/24/2024 the Director reported the two circular holes approximately two inches in diameter on the floor of the bathroom closest to the kitchen on the first floor of the facility to the Facilities Manager.
The safety committee will check floors, walls, ceilings and other surfaces to ensure they are in good repair monthly during facility walkthrough.
Maintenance staff has repaired the two circular holes approximately two inches in diameter on the floor of the bathroom closest to the kitchen on the first floor of the facility. |
10/29/2024
| Implemented |
| 2380.67(a) | At 12:00PM on 10/23/2024, the interior ceiling of the microwave in the kitchen on the first floor was covered in food splatter and rust. At 12:06PM on 10/23/2024, the microwave in the kitchen on the bottom level had food splatter and rust. At 12:16PM on 10/23/2024, there was a hole in the wall, approximately six inches in diameter, above the closet directly outside the program area on the lower level of the facility. | Furniture and equipment shall be nonhazardous, clean and sturdy. | On 10/24/2024 the Director removed the microwave in the kitchen on the first floor and the microwave in the kitchen on the bottom level.
The Director immediately reported the hole in the wall approximately six inches in diameter, above the closet directly outside the program area on the lower level of the facility to the Facility Manager.
Microwaves have been replaced and all program appliances have been checked to ensure that they are nonhazardous, clean and sturdy. |
11/06/2024
| Implemented |
| 2380.69(e) | There was no trash receptacle in the bathroom closest to the kitchen on the first floor of the facility. | Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer. | On 10/24/2024 the Director placed a trash receptacle in the bathroom closest to the kitchen on the first floor of the facility. |
11/07/2024
| Implemented |
| 2380.86 | At 12:12PM on 10/23/2024, there was a portable space heater in a storage closet. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices. | On 10/23/2024 the director removed the space heater from the program. |
10/24/2024
| Implemented |
| 2380.111(a) | Individual #3's most recent physical examination was completed on 9/11/2023. Individual #5 had a physical examination completed on 5/17/2022 and then again on 3/25/2024. [Repeat Violation, 10/27/2023] | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The director will ensure that current and previous physical examination dates are tracked on a master spreadsheet to maintain compliance within an annual date range.
The director will review the spreadsheet with the Clinical Administrator during weekly supervision to ensure compliance.
Should a physical examination not be provided to the program within the annual requirement, the individual will not be permitted to attend program pending provision of the physical examination. |
11/07/2024
| Implemented |
| 2380.111(c)(8) | Individual #2's physical examination, completed 3/7/2024, does not address physical limitations. This section was left blank. | The physical examination shall include: Physical limitations of the individual. | The program secretary requested to residential staff on 10/24/2024 that Individual #2¿s physical examination, completed 3/7/2024 to be complete.
A complete physical for Individual #2 was received 11/11/2024.
Files have been reviewed on 11/7/2024; this is a non-systemic issue.
Program secretary was trained in reviewing physicals when provided by the residential staff or families for completeness and will requesting updates to the physical examinations if needed on11/13/2024. |
11/13/2024
| Implemented |
| 2380.173(1)(ii) | Individual #1's record does not include identifying marks. Individual #2's record does not include identifying marks. Individual #3's record does not include identifying marks. Individual #5's record does 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. | Individual #1¿s record was updated to include identifying marks on 10/24/2024. Individual #2¿s record was updated on 10/24/2024 to include identifying marks. Individual #3¿s record was updated on 10/24/2024 to include identifying marks. Individual #5¿s record was updated on 10/24/2024 to include identifying marks. The updates were conducted by the program secretary. |
11/13/2024
| Implemented |
| 2380.173(1)(v) | Individual #2's record does not include a current, dated photograph. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | Program secretary will add the initial assessment for new individuals to the Program Specialist¿s schedules 45 days from start.
Program secretary was trained in adding initial assessments for new individuals to the Program Specialist schedules 11/13/2024.
Annual assessments are being tracked on a master spreadsheet. The director will now review the spreadsheet with the Clinical Administrator during weekly supervision to ensure compliance. |
11/13/2024
| Implemented |
| 2380.181(a) | Individual #1, date of admission 6/28/2024, had an initial assessment completed on 9/23/2024. Individual #2, date of admission 5/3/2024, had an initial assessment completed on 7/5/2024. Individual #4 had an assessment completed on 4/10/2023 and then again on 5/10/2024. Individual #5's annual assessment was completed 8/10/2022 and then again on 11/1/2023. [Repeat Violation, 10/27/2023] | 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 secretary will add the initial assessment for new individuals to the Program Specialist¿s schedules 45 days from start.
Program secretary was trained in adding initial assessments for new individuals to the Program Specialist schedules 11/13/2024.
Annual assessments are being tracked on a master spreadsheet. The director will now review the spreadsheet with the Clinical Administrator during weekly supervision to ensure compliance. |
11/13/2024
| Implemented |
| 2380.181(e)(12) | Individual #1's assessment, completed 9/23/2024, does not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. This section was left blank. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Recommendations for specific areas of training, vocational programming and competitive community-integrated employment were added to the 9/23/2024 assessment by the program Specialist. Assessment was presented to the team members with updated recommendations on 11/1/2024. |
11/01/2024
| Implemented |
| 2380.21(u) | Individual #5 was informed of and explained Individual Rights on 1/24/2023 and then again on 5/10/2024. [Repeat Violation, 10/27/2023] | 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. | Specialists were retrained on completing Individual Rights on 11/1/2024. |
11/01/2024
| Implemented |
| 2380.36(b) | Chief Executive Officer Designee #1 most recently completed fire safety training on 10/4/2022. Program Specialist #2 most recently completed fire safety training on 6/12/2023. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Chief Executive Officer Designee #1 and Program Specialist #2 were trained on fire safety training on 11/1/2024. |
11/01/2024
| Implemented |
| 2380.126(a)(10) | Individual #6's October 2024 Medication Administration Record does not include the administration time for Creon DR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Individual #6¿s Medication Administration Record has been updated to include the administration time for Creon DR on 11/1/2024. |
11/01/2024
| Implemented |
| 2380.126(a)(11) | Individual #6's October 2024 Medication Administration Record does not include the diagnosis for Creon DR. Individual #7's October 2024 Medication Administration Record does not include the diagnosis for Baclofen. | 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. | The diagnosis was added for Individual #6¿s and Individual #7¿s November 2024 Medication Administration Record on 11/1/2024. |
11/01/2024
| Implemented |
| 2380.129(a) | Direct Service Worker #3 administered all medications throughout September and October 2024. Direct Service Worker #3 most recently completed the Modified Medication Administration Training on 3/17/2022 and has not completed the required annual practicums. | 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). | Direct Service Worker #3 immediately stopped administering medications on 10/23/2024.
Residential staff for individual #6 administered medications from 10/23/2024 to 10/31/2024.
Family for individual #7 administered medications from 10/23/2024 to 10/31/2024.
Program Nurse was brought in to administer medications on 11/1/2024 pending completion of staff training.
Due to Individual #1¿s PRN he will not attend the program pending completion of staff training. |
11/07/2024
| Implemented |
| 2380.173(1)(i) | Individual #2's record does not include a Social Security Number. | The name, sex, admission date, birthdate and Social Security number. | Individual #2¿s Social Security Number was added to the record by the program secretary on 10/28/2024. |
11/13/2024
| Implemented |
| 2380.173(5) | Individual #1's record did not include the most recent Individual Service Plan. Individual #2's record did not include the most recent Individual Service Plan. Individual #3's record did not include the most recent Individual Service Plan. Individual #4's record did not include the most recent Individual Service Plan. Individual #5's record did not include the most recent Individual Service Plan. | Individual plan documents as required by this chapter. | Individual #1, Individual #2, Individual #4 and Individual #5¿s most recent Individual Service Plan was added to the file by the program secretary on 10/24/2024. |
11/13/2024
| Implemented |
| 2380.181(f) | Program Specialist #2 provided Individual #4's assessment to the plan team on 5/13/2024 for the annual plan meeting on 5/10/2024. [Repeat Violation, 10/27/2023] | 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 secretary will add the due dates for sending assessments to her outlook calendar to ensure the document is sent prior to 30 days from the individual plan meeting. The program secretary has been trained on the adding send dates for assessments to the outlook calendar on 11/13/2024. |
11/13/2024
| Implemented |
|
|
|
SIN-00233445
|
Renewal
|
10/27/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.91(a) | Individual #2 received training 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, and smoking safety procedures if individuals smoke at the facility on 11/24/21, and then again on 07/25/23. This exceeds the annual requirement. [Repeat violation 11/10/22] | 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. | Individual #2 received training in general fire safety on 11/22/22. The training was not filed at the time of licencing. |
11/13/2023
| Implemented |
| 2380.111(a) | Individual #2's most recent physical examination was completed on 09/06/22. This exceeds the annual requirement. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2's most recent physical examination was completed on 9/12/23. Individual #2's physical was not filed at the time of Licensing. |
11/15/2023
| Implemented |
| 2380.113(a) | Direct Service Worker #3 had a physical examination completed on 11/16/20, and then again on 04/17/23. | 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. | Human Resources send notification to the employees and the supervisor at least one month prior to the physical due date. |
11/15/2023
| Implemented |
| 2380.181(a) | Individual #1 had an annual assessment completed on 09/08/21, and then again on 12/08/22. This exceeds the annual requirement. Individual #3 had an assessment completed on 11/02/21, and then again on 11/30/22. This exceeds the annual requirement. [Repeat violation 11/10/22] | 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. | Due to the lack of notice provided by ISC's as to when the ISP is scheduled, Assessments will be completed more than 30 days prior to the last ISP date. Individual assessments will be tracked on a master spreadsheet and completed by the program specialists more than 30 days prior to date of last ISP. |
11/15/2023
| Implemented |
| 2380.21(u) | Individual #1 was informed of and explained their individual rights on 10/21/21, and then again on 11/21/22. This exceeds the annual requirement. | 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. | Individual rights are most often completed during the ISP meeting. Due to lack of control of when the ISP occures, Individual rights will now be completed withing 365 days of the last Individual Rights. |
11/15/2023
| Implemented |
| 2380.36(a) | Direct Service Worker #2, hire date of 08/07/23, did not receive fire safety training prior to working with individuals. | 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. | Direct Service Worker #2 received Fire Safety training on 11/13/2023. |
11/13/2023
| Implemented |
| 2380.38(b)(1) | Direct Service Worker #2, hire date of 08/07/23, was not trained on person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships within 30 days of hire. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Direct Service Worker #2 received training on Person-centered practices, community integration and Individual choice on 11/13/2023. Direct Service Worker #2 received training on supporting individuals to develop and maintain relationships on 11/14/2023. |
11/13/2023
| Implemented |
| 2380.38(b)(2) | Direct Service Worker #2, hire date of 08/07/23, was not trained on 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.within 30 days of hire. | The orientation 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. | Direct Service Worder #2 received training on prevention, detection, and reporting of abuse on 11/14/2023. |
11/13/2023
| Implemented |
| 2380.38(b)(3) | Direct Service Worker #2, hire date of 08/07/23, was not trained on individual rights within 30 days of hire. | The orientation must encompass the following areas: Individual rights. | Direct Service Worker #2 received individual rights training on 11/14/2023. |
11/14/2023
| Implemented |
| 2380.39(c)(3) | Program Specialist #1's training for the annual training year 07/01/22 to 06/30/23 did not include training on individual rights. [Repeat violation 11/10/22] | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Program Specialist #1 received individual rights training on 11/13/2023. |
11/13/2023
| Implemented |
| 2380.181(f) | Individual #1's annual assessment, completed on 12/08/22, was sent to the Plan Team on 12/08/22, after the annual ISP meeting that occurred on 10/18/22. Individual #3's annual assessment, completed on 11/30/22, was sent to the Plan Team on 11/30/22, in preparation for an annual ISP meeting that occurred on 12/01/22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Due to the lack of notice provided by ISC's as to when the ISP is scheduled, Assessments will be completed more than 30 days prior to the last ISP date. Individual assessments will be tracked on a master spreadsheet and completed by the program specialists more than 30 days prior to date of last ISP. |
11/13/2023
| Implemented |
| 2380.182(c) | Individual #1's annual ISP meeting was conducted on 10/18/22 with an annual assessment that was completed and sent to the team on 09/08/21. No current assessment was provided prior to the ISP meeting. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Due to the lack of notice provided by ISC's as to when the ISP is scheduled, Assessments will be completed more than 30 days prior to the last ISP date. Individual assessments will be tracked on a master spreadsheet and completed by the program specialists more than 30 days prior to date of last I |
11/13/2023
| Implemented |
|
|
|
SIN-00214451
|
Renewal
|
11/10/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(c)(2) | Program Specialist #1, date of hire 6/15/22, bachelor's degree obtained 5/15/10 from Youngstown University, does not have 2 years of work experience working directly with persons with disabilities. | A program specialist shall have one of the following groups of qualifications:(2) A bachelor¿s degree from an accredited college or university and 2 years of work experience working directly with persons with disabilities. | Program Specialist #1 provided Chartiers Center a resume with three years experience in a tutoring program. |
11/23/2022
| Implemented |
| 2380.91(a) | Individual #1, date of admission 7/29/22 and Individual #2, date of admission 3/16/22 had training in general fire safety 8/1/22 and 3/21/22, respectively. Individual #4 had training in general fire safety 5/5/21 and then again 5/23/22. | 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. | All individuals attending Chartiers Center day program have current fire safety training. |
11/22/2022
| Implemented |
| 2380.111(a) | The most recent physical examination for Individual #4 was completed 2/5/21. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual has a more current physical examination that was incomplete and sent back to the family to get the Doctor to complete. It was not returned. During the last 10 days we have attempted to contact the individuals familyto get the physical. Individual's Service Coordinator was contacted on 11/20/2022, she does not have a physical. She contacted the family who report they do not have the physical. We have sent home a new physical form on 11/14,17,21/22. Individual #4 will not attend program pending a new physical. |
11/23/2022
| Implemented |
| 2380.111(c)(4) | Individual #1's physical examination, completed 11/1/21, did not include a vision screening. On the physical examination form, under the column labeled "evaluate further" it states "see opth". No additional documentation was provided. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Vision evals were requested on 11/14/2022, Lifesharing specialist is getting the vision screening evaluations and will provide to Chartiers Center by 11/30/2022. |
11/23/2022
| Implemented |
| 2380.111(c)(7) | Individual #1's physical examination completed 5/17/22, 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. | Contacted Individual #1¿s doctor to get the physical complete on 11/14 and 11/17 and 11/21, did not hear back. We will continue to make attempts to get the information on the physical until a complete physical is acuired. |
11/23/2022
| Implemented |
| 2380.113(a) | Casual Program Specialist #3 had physical examinations completed 1/10/20 and then again 1/27/22, Temporary Direct Service Worker #4, date of hire 6/21/21, had a physical examination completed 5/18/22. | 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. | Casual Program Specialist #3 is rarely scheduled for work and was not scheduled to work until after completion of the physical on 1/27/22. Temporary Direct Service Worker #4 was reviewed during our 2021 Licensing Inspection and the Pre-employment form provided by Capital Healthcare was accepted at that time, she has since provided a current physical dated 5/18/22. |
11/23/2022
| Implemented |
| 2380.113(c)(2) | Casual Program Specialist #3 had Tuberculin skin testing with negative results completed 1/13/20 and then again 2/2/22. There was no Tuberculin skin testing with negative results documentation provided for Temporary Direct Service Worker #4. Therefore, compliance could not be measured. [Repeat violation 12/17/21] | 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. 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. | Casual Program Specialist #3 was due for physical 1/10/2022; she had it completed on 1/27/2022. She was due for her tb on 1/13/2022 ; she had it completed on 2/2/2022.
She did not work from 1/10/2022 ¿ 2/3/2022, she was not working with clients. She returned to work on 2/4/2022.
We have requested Turberculin skin testing from Capital Healthcare for Temporary Direct Service Worker #4. Results were provided. |
11/23/2022
| Implemented |
| 2380.181(a) | Individual #1, date of admission 3/16/22, had an initial assessment completed 11/9/22. Individual #3 had assessments completed 10/15/20 and then again 11/5/21. Individual #4, date of admission 7/1/15, had an assessment completed 5/31/22. [Repeat Violation 12/17/21] | 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 #1 had an assessment completed by residential house manager completed 7/27/22 prior to start date of 8/1/22. This assessment was not provided at time of review. |
11/21/2022
| Implemented |
| 2380.181(d) | Individual #2's 11/9/22 assessment is not signed or dated by a program specialist. | The program specialist shall sign and date the assessment. | Due to a technical issue the assessment was unable to be signed at the time of licensure. We reached out to our IT department and the issue has been resolved.. Assessment has now been signed and dated. |
11/23/2022
| Implemented |
| 2380.181(e)(12) | Individual #2's 11/9/22 assessment does not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. These sections were left blank. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Assessment has been completed with recommendations for specific areas of training, vocational programming and competitive community-integrated employment. |
11/23/2022
| Implemented |
| 2380.21(u) | The Individual Rights signed by Individual #1, 8/1/22, Individual #2, 3/21/22, Individual #3, 6/28/21 and Individual #4, 5/23/22 did not include the following rights: a) An individual may not be deprived of rights; b) The facility shall educate, assist and provide the accommodation necessary for the individual to understand the individual's rights; (e) A court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; (f) An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; (h) An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; (i) An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion; (o) An individual has the right of access to and security of the individual's possessions; (r) An individual's rights shall be exercised so that another individual's rights are not violated; (s) The facility shall assist the affected individuals to negotiate choices in accordance with the facility's procedures for the individuals to resolve differences and make choices; (t) An individual's rights may only be modified in accordance with § 2380.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. Individual #4 signed their Individual Rights 5/5/21 and then again 5/23/22. | 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. | Individual rights have been updated on 11/21/22 to include a) An individual may not be deprived of rights; b) The facility shall educate, assist and provide the accommodation necessary for the individual to understand the individual's rights; (e) A court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; (f) An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; (h) An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; (i) An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion; (o) An individual has the right of access to and security of the individual's possessions; (r) An individual's rights shall be exercised so that another individual's rights are not violated; (s) The facility shall assist the affected individuals to negotiate choices in accordance with the facility's procedures for the individuals to resolve differences and make choices; (t) An individual's rights may only be modified in accordance with § 2380.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. |
11/23/2022
| Implemented |
| 2380.36(a) | Director/Acting Chief Executive Officer #2, Casual Program Specialist #3, Temporary Direct Service Worker #4, Direct Service Worker #6 and Direct Service Worker #7 did not receive training in general fire safety during training year 7/1/21-6/30/22. [Repeat violation 12/17/21] | 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. | Director/Acting Chief Executive Officer #2, Temporary Direct Service Worker #4, Direct Service Worker #6 and Direct Service Worker #7 have taken new fire safety training as of 11/18/2022. Casual Program Specialist #3 will not be scheduled to work pending completion of fire safety training, |
11/21/2022
| Implemented |
| 2380.38(a)(3) | Program Specialist #1, date of hire 6/15/22, Temporary Direct Service Worker #4, date of hire 6/21/21 and Direct Service Worker #6, date of hire 10/11/21, did not receive Orientation prior to working alone with individuals, and within 30 days after hire. [Repeat Violation 12/17/21]. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Program Specialist #1 date of hire 6/15/2022 had orientation on 6/15/2022 and was provided.
Temporary Direct Service Worker #4 completed a New Hire Orientation after last Licensing dated 1/12/2022.
Direct Service Worker #6 was reviewed during last years licensing and had a New Hire Orientation dated 10/13/2021 her first day on site. |
11/23/2022
| Implemented |
| 2380.39(a)(1) | Casual Program Specialist #3 completed 1.75 hours of training for training year 7/1/21-6/30/22. Direct Service Worker #6 completed 2.5 hours of training for training year 7/1/21-6/30/22. | The following shall complete 24 hours of training related to job skills and knowledge each year: Directive service workers. | New training schedule developed 11/21/2022 to maintain compliance. Program Director as well as Program Secretary will maintain and track staff training utilizing the new training schedule. Casual Program Specialist #3 will be scheduled to complete trainings before working with individuals. |
11/23/2022
| Implemented |
| 2380.39(b)(1) | Director/Acting Chief Executive Officer #2 completed 7.5 hours of training for training year 7/1/21-6/30/22. | The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | Director/Acting Chief Executive Officer #2 has 23.5 hours of training for the current training year and will follow the new training schedule developed 11/21/2022 to further maintain compliance. |
11/21/2022
| Implemented |
| 2380.39(c)(1) | Director/Acting Chief Executive Officer #2, Casual Program Specialist #3, Direct Service Worker #5, and Direct Service Worker #6 did not receive training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during training year 7/1/21-6/30/22. | 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. | Director/Acting Chief Executive Officer #2, Direct Service Worker #5, and Direct Service Worker #6 received training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships as of 11/23/2022.
Casual Program Specialist #3 will not be scheduled to work pending completion of training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. |
11/21/2022
| Implemented |
| 2380.39(c)(2) | Casual Program Specialist #3 did not receive training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: 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. | Casual Program Specialist #3 will not be scheduled to work pending completion of training in prevention, detection and reporting abuse, suspected abuse and alleged abuse training. |
11/21/2022
| Implemented |
| 2380.39(c)(3) | Director/Acting Chief Executive Officer #2, Casual Program Specialist #3, Direct Service Worker #5 and Direct Service Worker #7 did not receive training in Individual rights during training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Director/Acting Chief Executive Officer #2, Direct Service Worker #5 and Direct Service Worker #7 have received training in Individual rights as of 11/22/22. |
11/22/2022
| Implemented |
| 2380.39(c)(4) | Casual Program Specialist #3, Direct Service Worker #5 and Direct Service Worker #7 did not receive training in recognizing and reporting incidents during training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Direct Service Worker #5 and Direct Service Worker #7 received training in recognizing and reporting incidents on 11/21/2022. |
11/21/2022
| Implemented |
| 2380.39(c)(5) | Director/Acting Chief Executive Officer, #2, Casual Program Specialist #3, Direct Service Worker #5 and Direct Service Worker #7 did not receive training in the safe and appropriate use of behavior supports if the person works directly with an individual during training year 7/1/21-6/30/22. | 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. | Director/Acting Chief Executive Officer, #2 received training on safe and appropriate use of behavior supports as of 11/22/22.
Casual Program Specialist #3 will not be scheduled to work pending completion of training on safe and appropriate use of behavior supports.
Direct Service Worker #5 and #7 do not work with an individual with a behavior support plan. |
11/22/2022
| Implemented |
| 2380.39(c)(6) | Director/Acting Chief Executive Officer, #2, Casual Program Specialist #3, Direct Service Worker #5 and Direct Service Worker #7 did not receive training in implementation of the individual plan if the person works directly with an individual during training year 7/1/21-6/30/22. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All Chartiers Center staff sign off on each ISP once approved. These sign off sheets were not provided during review. |
11/23/2022
| Implemented |
| 2380.181(f) | Individual #3's 11/5/21 assessment was provided to the individual plan team members 11/5/21 for an annual ISP meeting held 12/1/21. Individual #4's 5/31/22 assessment was provided to the individual plan team members 5/23/22 for an annual ISP meeting held 5/18/22. [Repeat violation 12/17/21] | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Master spreadsheet developed 11/21/2022 will be utilized to track dates to ensure timely completion of assessments. All assessments will be tracked by and reviewed by Program Specialists and Program Director to determine compliance. |
11/23/2022
| Implemented |
|
|
|
SIN-00198356
|
Renewal
|
12/17/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(a) | Direct Service Worker #7, date of hire 6/21/2021, did not have a criminal background check requested. | 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. | Direct Service Worker #7 is a temp staff. I contacted the agency that she works for and acquired the Pennsylvania criminal history record check on 1/13/22. |
01/13/2022
| Implemented |
| 2380.59(b) | The water temperature in Bathroom #3 on the lower floor in the lunch area measured 140.7°F at 1:56 PM. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The water temperature in Bathroom #3 on the lower floor in the lunch area measured 140.7 at 1:56pm, the water temperature was reduced on the water heater and rechecked once more and was found to be in compliance during our review and deemed compliant by the licensing representative. |
01/12/2022
| Implemented |
| 2380.113(c)(2) | The Tuberculin skin test completed 6/1/2020 for Chief Executive Officer #1 did not include the medical credentials of who read the test, so compliance was unable to be measured. The Tuberculin skin test completed 1/13/2020 for Program Specialist #2 did not include the medical credentials of who read the test, so compliance was unable to be measured. | 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. 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. | The physical form has been changed to allow for the credentials of those who read the Tuberculin skin test on 1/14/2022. |
01/14/2022
| Implemented |
| 2380.181(a) | Individual #1 had an assessment completed on 7/1/2020 and again on 9/7/2021. Individual #4 had an assessment completed on 7/10/2020 and again on 8/27/2021. | 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 spreadsheet has been developed for all participants to show the dates of all information and assessments and when they are due next. The spreadsheet will be maintained by the program secretary allowing the dates to be added to the Program Specialist's Outlook calendar. |
01/14/2022
| Implemented |
| 2380.21(u) | Individual #1 was informed and explained individual rights on 9/8/2021. Individual #2 was informed and explained individual rights on 7/12/2021. Individual #3, date of admission 7/19/2021, was informed and explained individual rights on 7/12/2021. Individual #4 was informed and explained individual rights on 8/19/2021. The rights documents did not include the following rights: the right to 2380.21c, not be reprimanded, punished, or retaliated against for exercising rights; 2380.21g, to designate persons to assist in decision making and exercising rights; 2380.21l, to make choices and accept risks; 2380.21m, to refuse to participate in activities and services; and 2380.21o, access to and security of possessions. | 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. | Individual #3's date of admission submitted was incorrect. The date of admission was 7/12/2022. The rights form was updated to include the right to 2380.21c, not be reprimanded, punished, or retaliated against for exercising rights; 2380.21g, to designate persons to assist in decision making and exercising rights; 2380.21l, to make choices and accept risks; 2380.21m, to refuse to participate in activities and services; and 2380.21o, access to and security of possessions. Individuals #2&3 were informed and explained of individual rights on 1/14/2022. Individuals 1& 4 will be informed and explained of rights immediately upon return to program. |
01/13/2022
| Implemented |
| 2380.36(a) | Direct Service Worker #3, date of hire 10/11/2021, was not initially trained in Fire Safety. | 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. | Direct Service Worker #3 was trained on Fire Safety on 1/13/2022. |
01/14/2022
| Implemented |
| 2380.36(b) | Program Specialist #2 has not been trained in Fire Safety. Direct Service Worker #4 was trained in Fire Safety on 6/14/2021. The previous fire safety training was not provided; therefore, compliance was unable to be measured. Direct Service Worker #6 was trained in Fire Safety on 3/15/2021. The previous fire safety training was not provided; therefore, compliance was unable to be measured. Direct Service Worker #5 was trained in Fire Safety on 6/9/2021. The previous fire safety training was not provided; therefore, compliance was unable to be measured. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Program Specialist #2 will is a casual staff and will be trained on Fire Safety immediately upon her next scheduled shift. |
01/13/2022
| Implemented |
| 2380.37(a) | The record of training for Direct Service Worker #7 did not include the dates or source of the training. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | Direct Service Worker #7 is a temporary staff from an agency that does not include the dates or source of the trainings. Chartiers Center will now complete our own orientation as well as annual trainings for agency staff. |
01/14/2022
| Implemented |
| 2380.38(b)(2) | Direct Service Worker #7's orientation training did not encompass the Prevention, Detection, and Reporting of Abuse. | The orientation 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. | Direct Service Worker #7 is a temporary staff from an agency who's orientation training did not encompass the Prevention, Detection, and Reporting of Abuse. Direct Service Worker #7 was trained on Prevention, Detection, and Reporting of Abuse on 1/13/2022. |
01/13/2022
| Implemented |
| 2380.38(b)(3) | Direct Service Worker #7's orientation training did not encompass Individual Rights. | The orientation must encompass the following areas: Individual rights. | Direct Service Worker #7 is a temporary staff from an agency who's orientation training did not encompass Individual Rights. Direct Service Worker #7 was trained on Individual Rights on 1/13/2022. |
01/13/2022
| Implemented |
| 2380.38(b)(4) | Direct Service Worker #3's orientation training did not encompass Recognizing and Reporting Incidents. | The orientation must encompass the following areas: Recognizing and reporting incident. | Direct Service Worker #3 was trained on Recognizing and Reporting Incidents on 1/13/2022. |
01/14/2022
| Implemented |
| 2380.39(c)(2) | Chief Executive Officer #1's training for training year from 7/1/2020 to 6/30/2021 did not encompass the Prevention, Detection, and Reporting of Abuse. Program Specialist 2's training for training year from 7/1/2020 to 6/30/2021 did not encompass the Prevention, Detection, and Reporting of Abuse. | 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. | Chief Executive Officer #1 was trained on Prevention, Detection, and Reporting of Abuse on 1/13/2022. Program Specialist #2 is a temporary staff and will be trained upon her next scheduled shift. |
01/14/2022
| Implemented |
| 2380.39(c)(4) | Direct Service Worker #4's training for training year from 7/1/2020 to 6/30/2021 did not encompass Recognizing and Reporting Incidents. Direct Service Worker #5's training for training year from 7/1/2020 to 6/30/2021 did not encompass Recognizing and Reporting Incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Direct Service Worker #4 and #5 was trained on Recognizing and Reporting Incidents on 1/14/2022. |
01/14/2022
| Implemented |
| 2380.181(f) | The program specialist did not provide Individual #1 assessment, completed 9/7/2021, to the individual plan team members for the individual plan meeting on 9/10/2021. The program specialist did not provide Individual #4 assessment, completed 8/27/2021, to the individual plan team members for the individual plan meeting on 8/19/2021. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | A spreadsheet has been developed for all participants to show the dates of all information and assessments and when they are due next. The spreadsheet will be maintained by the program secretary allowing the dates to be added to the Program Specialist's Outlook calendar. |
01/14/2022
| Implemented |
|
|
|
SIN-00149193
|
Renewal
|
01/29/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(h) | Chief Executive Officer #1 did not have records of training for training year, 7/1/17 to 6/30/18. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | During time of licensing I was unaware that I was the designated Chief Executive Officer of the program for purposes of licensing. As designated Chief Executive Officer, my training hours were to be provided. My training schedule will be sent to Human Services Licensing Supervisor on 2/28/19. [CEO qualifications were verified for CEO #2 by the Department on 3/12/19 during onsite inspection. CEO training hours were verified for CEO #2 by the Department on 3/12/19 during onsite inspection. Immediately, the agency shall develop an organizational chart and train all staff persons on the organizational system to ensure staff persons are aware of their positions and the qualifications and training required for their positions. "Documentation of the trainings shall be kept. At least quarterly for one year, the CEO or designee shall audit all staff persons trainings to ensure training records are documented as required and available for review upon request by the Department. (DPOC by AES, HSLS on 3/12/19)] |
02/28/2019
| Implemented |
| 2380.181(e)(11) | Individual #1's assessment completed 12/20/18 did not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | Individual #1's assessment did include the psychological evaluations information. We were unable to locate the information during licensing and during a review afterwards it was located in the electronic record. The information was located in the Annual Assessment under Assessment entry and titled Psychological Evaluation Information and reads as follows with the individuals name changed to Individual #1.
"Individual #1 MAY PERSEVERATE ON AN ISSUE OR MAY BE ARGUMENTATIVE. HE DOES RECEIVE MEDICATION TO ADDRESS ANXIETY AND OBSESSIVE COMPULSIVE SYMPTOMS.
Individual #1HAS A VERY HIGH TOLERANCE FOR FRUSTRATION. Individual #1TENDS TO DEAL WITH HIS ANGER BY WITHDRAWING, EATING, OR TALKING IT OUT IF HE CAN. WHEN Individual #1IS STRESSED, HE MAY STUTTER. Individual #1IS KNOWN TO PERSEVERATE ON ISSUES SOMETIMES AND THIS CAN LEAD TO HIM BEING ARGUMENTATIVE AND/OR ANXIOUS. WHEN Individual #1BECOMES ANXIOUS, HE WILL MAKE NUMEROUS PHONE CALLS TO HIS FRIENDS, STAFF, AND FAMILY MEMBERS TO TRY AND RELIVE HIS ANXIETY.
Individual #1IS A VERY COOPERATIVE PERSON. Individual #1IS MORE COOPERATIVE IF ASKED TO COMPLETE A CHORE. IF HE IS EXPLAINED A SITUATION BEFORE HANDS, HE RESPONDS VERY WELL. HE IS VERY UNDERSTANDING AND QUICK TO COOPERATE. AS FAR AS ATTENDING SOCIAL EVENTS/ACTIVITIES, Individual #1WAS NOT VERY RECEPTIVE TO PARTICIPATE WHEN HE FIRST MOVED IN TO HIS NEW HOME. HE HAS SINCE BECOME MORE OUTGOING AND EXCITED TO PARTICIPATE IN GROUP ACTIVITIES. " [Immediately, the CEO or designee shall request a copy of a Psychological Evaluation from Individual #'1's SC or other team members. Immediately, the CEO or designee shall audit all individuals' assessment to ensure a Psychological Evaluation is included in individuals' assessments, if applicable and obtain as needed. Immediately, upon hire and at least annually, the CEO or designee shall educate the program specialist(s) of the requirements of individuals' assessments as per 2380.181(e)(1)-(14). Documentation of training shall be kept. At least quarterly for 1 year, the CEO or designee shall audit all individuals' assessment to ensure all required information is included. Documentation of audits shall be kept. (DPOC by AES,HSLS on 3/12/19)] |
02/07/2019
| Implemented |
| 2380.186(a) | The program specialist completed Individual #1's ISP review, from 11/8/18 to 12/19/18, on 1/8/19.
The program specialist completed Individual #2's ISP review, from 9/6/18 to 12/5/18, on 1/2/19. The program specialist completed Individual #2's ISP review, from 3/6/18 to 6/5/18, on 6/27/18. The program specialist completed Individual #2's ISP review, from 12/6/17 to 3/5/18, on 4/4/18. | 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. | The Program Specialist was retrained on ISP review on 2/7/19. The training was specific to the timeframe of the process in line with PA Code Chapter 2380.186(a). The program secretary will track the ISP review process to ensure compliance with regulations. [Upon completion for one year, the CEO or designee shall audit a 25% sample of all individuals' ISP reviews and the aforementioned tracking system to ensure the program specialist(s) completes all individuals' ISP reviews, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/12/19)] |
02/07/2019
| Implemented |
| 2380.186(b) | Individual #1's ISP review, from 11/8/18 to 12/19/18, was not dated as to when signed by the individual. Individual #2's, ISP reviews from 9/6/18 to 12/5/18, 6/6/18 to 9/5/18 and 12/6/17 to 3/5/18 were not dated as to when signed by the individual. Individual #3's ISP reviews, from 8/29/18 to 11/28/18, 5/29/18 to 8/28/18 and 3/1/18 to 5/28/18, were not dated as to when signed by the individual. (Repeated Violation-2/14/18) | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The program specialist was retrained on ISP signature sheet process on 2/7/19. The training specified the requirements of the PA Code Chapter 2380.186(b). Program Secretary will track ISP reviews to ensure that the document contains a signature and date. [Upon completion for one year, the CEO or designee shall audit a 25% sample of all individuals' ISP reviews and the aforementioned tracking system to ensure the program specialist(s) and individuals sign and date the ISP reviews upon review. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/12/19)] |
02/07/2019
| Implemented |
|
|
|
SIN-00128683
|
Renewal
|
02/14/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(6) | Individual #2's physical examination completed 9/20/17 did not address communicable disease; therefore, compliance could not be measured. | 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. | Immediate Corrective Action Plan:
The most recent physical examination form for Individual #2 was faxed to the primary care physician¿s office to be amended to provide information on communicable disease by the secretary of IDD Day Programs on 2/15/2018. The updated information was received for the physical form on 2/19/18 and filed in the individual¿s record.
Long-Term Corrective Action Plan:
The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a review of all the physical forms for each individual that attends the ETC and SCC programs using the program censuses as a guide. The review of physical forms will be completed by 3/16/2018. During the physical form review process and on an ongoing basis when physical forms are received by the secretary of IDD Day Programs, the physical form will be reviewed against PA Code 2380 regulations pertaining to required information to be included in the physical documentation. This includes information pertinent to communicable disease. When areas of information are discovered to be missing on an individual¿s physical form, the secretary of IDD Day Programs will fax a letter of request to the physicians' office requesting the missing information. The missing information received following the request shall be signed by the physician or designee (as specified in the PA Code 2380.11(b)) and will be added as an addendum stapled to the physical form. The secretary of IDD Day Programs will maintain a folder of all faxed requests. When the information is complete secretary of IDD Day Programs will denote on the request the date and time the information was received and ensure the information is filed in the individual¿s record. In instances where 1 week, has elapsed and the information has not yet been received, she will send a second request via fax to the physician's office. Once all physical information is complete, the secretary will let the Director of IDD Day Programs know via email that all actionable items have been addressed pertaining to the individual¿s physical form. The secretary of IDD Day programs will be trained on this process 2/28/2018. Beginning, April 1, 2018, The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a random audit of 10% of the individuals' records in the ETC and SCC every 3 months as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day following the previously outlined physical form corrective action process. |
03/16/2018
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination completed 9/20/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination completed 9/20/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #3's physical examination completed 6/13/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Immediate Corrective Action Plan:
The most recent physical examination forms for Individuals #1, #2 and 3 were faxed to the primary care physician¿s office to be amended to include medical information pertinent to diagnosis and treatment in case of emergency by the Director of IDD Day Programs on 2/15/2018. The updated physical forms were received between 2/15/18 and 2/20/18 and filed in the individual¿s record.
Long-Term Corrective Action Plan:
The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a review of all the physical forms for each individual that attends the ETC and SCC programs using the program censuses as a guide. The review of physical forms will be completed by 3/17/2018. During the physical form review process and on an ongoing basis when physical forms are received by the secretary of IDD Day Programs, the physical form will be reviewed against PA Code 2380 regulations pertaining to required information to be included in the physical documentation. This includes medical information pertinent to diagnosis and treatment in case of emergency. When areas of information are discovered to be missing on the physical form, the secretary of IDD Day Programs will fax a letter of request to the physicians' office requesting the missing information. The missing information received following the request will be signed by the physician or designee (as specified in the PA Code 2380.111(b)) and will be added as an addendum stapled to the physical form. The secretary of IDD Day Programs will maintain a folder of all faxed requests. When the information is complete secretary of IDD Day Programs will denote on the request the date and time the information was received and ensure the information is filed in the individual¿s record. In instances where 1 week, has elapsed and the information has not yet been received, she will send a second request via fax to the physician's office. Once all physical information is complete, the secretary will let the Director of IDD Day Programs know via email that all actionable items have been addressed pertaining to the individual¿s physical form. The secretary of IDD Day programs will be trained on this process 2/28/2018. Beginning, April 1, 2018, The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a random audit of 10% of the individuals' records in the ETC and SCC every 3 months as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day following the previously outlined physical form corrective action process. |
03/16/2018
| Implemented |
| 2380.181(f) | The program specialist provided Individual #1's assessment completed 4/25/17 to the plan team members on 8/8/17 for the annual ISP meeting held 8/28/17. The program specialist provided Individual #3's assessment completed 4/14/17 to the plan team members on 4/20/17 for the annual ISP meeting held 5/12/17.
The program specialist provided Individual #4's assessment completed 10/11/17 to the plan team members on 10/13/17 for the annual ISP meeting held 11/8/17. | 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). | Immediate Corrective Action Plan
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).
Long-term Corrective Action Plan
The Program Specialist shall sign off on assessments and notify Director of IDD Day Programs of submission. IDD Director shall sign off on assessments, if no addendum is required, will immediately notify Secretary of IDD Day Program of completion. The Secretary will print out assessments, and face sheets to mail to authorized parties by the next business day. The Secretary shall give completed assessments and face sheets to the Program Specialists to sign and have the individual¿s signature and date placed on the form. IDD Secretary will notify the Program Specialist of time frame remaining to get the completed documents out 30 days prior to ISP meeting in accordance with PA Code 2380.181.F. Program Specialist and IDD Secretary will receive training on 02/28/2018. Beginning, April 1, 2018, The Director of IDD Day Programs and the Secretary of IDD Day Programs will complete a random audit of 10% of the individuals' records in the ETC and SCC every 3 months as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day following the previously outlined physical form corrective action process. |
03/16/2018
| Implemented |
| 2380.186(b) | Individual #1's ISP review for period 5/8/17 through 8/7/17 was signed and dated by the individual on 2/8/18.
Individual #3's ISP review for period 5/9/17 through 8/8/17 was signed and dated by the individual on 2/13/17. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Immediate Corrective Action Plan:
During an internal file audit completed on 2/2/18 it was found that Individual #1 had no documentation to show that an ISP review for period 5/8/17 through 8/7/17 was provided to the plan team members. Therefore an ISP review was reprinted and signed and provided to the team lead on 2/2/18.
During an internal file audit completed on 2/13/18 it was found that Individual #1 had no documentation to show that an ISP review for period 5/9/17 through 8/8/17 was provided to the plan team members. Therefore an ISP review was reprinted and signed and provided to the team lead on 2/2/18 . As the ISP review period for Individual #1¿s and Individual #3¿s ISP review has passed and the documents were signed, no further immediate action is possible.
Long-Term Corrective Action Plan:
The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a review of all ISP reviews for each individual that attends the ETC and SCC programs using the program censuses as a guide. The review of ISP reviews will be completed by 3/16/2018. During the review process any ISP reviews without documentation showing that the review was delivered to the plan lead, the review will be reprinted and signed and delivered to the plan lead. On an ongoing basis the Program Specialists will continue to complete the ISP reviews as outlined in PA Code 2380 regulations pertaining to ISP reviews. The Director of IDD Day Programs will continue to sign off on ISP reviews following their completion by the Program Specialist. The Secretary of IDD Day Programs will ensure that ISP reviews are complete and signed and will provide to the plan lead as well as keep documentation that the ISP review has been provided to the plan lead as outlined in PA Code 2380. The secretary of IDD Day programs will be trained on this process 2/28/2018. Beginning, April 1, 2018, The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a random audit of 10% of the individuals' records in the ETC and SCC every 3 months as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day following the previously outlined physical form corrective action process. |
03/16/2018
| Implemented |
| 2380.186(d) | The program specialist provided Individual #1's ISP review for period 5/8/17 through 8/7/17 to the plan team members on 2/2/18. The program specialist provided Individual #3's ISP review for period 5/9/17 through 8/8/17 to the plan team members on 2/13/18. | 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. | Immediate Corrective Action Plan:
During an internal file audit completed on 2/2/18 it was found that Individual #1 had no documentation to show that an ISP review for period 5/8/17 through 8/7/17 was provided to the plan team members. Therefore an ISP review was reprinted and signed and provided to the team lead on 2/2/18.
During an internal file audit completed on 2/13/18 it was found that Individual #1 had no documentation to show that an ISP review for period 5/9/17 through 8/8/17 was provided to the plan team members. Therefore an ISP review was reprinted and signed and provided to the team lead on 2/2/18. As the ISP review period for Individual #1¿s and Individual #3¿s ISP review has passed and the documents were signed, no further immediate action is possible.
Long-Term Corrective Action Plan:
The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a review of all ISP reviews for each individual that attends the ETC and SCC programs using the program censuses as a guide. The review of ISP reviews will be completed by 3/16/2018. During the review process any ISP reviews without documentation showing that the review was delivered to the plan lead, the review will be reprinted and signed and delivered to the plan lead. On an ongoing basis the Program Specialists will continue to complete the ISP reviews as outlined in PA Code 2380 regulations pertaining to ISP reviews. The Director of IDD Day Programs will continue to sign off on ISP reviews following their completion by the Program Specialist. The Secretary of IDD Day Programs will ensure that ISP reviews are complete and signed and will provide to the plan lead as well as keep documentation that the ISP review has been provided to the plan lead as outlined in PA Code 2380. The secretary of IDD Day programs will be trained on this process 2/28/2018. Beginning, April 1, 2018, The Director of IDD Day Programs and the secretary of IDD Day Programs will complete a random audit of 10% of the individuals' records in the ETC and SCC every 3 months as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day following the previously outlined physical form corrective action process. |
03/16/2018
| Implemented |
|
|
|
SIN-00109425
|
Renewal
|
02/28/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(d) | The evacuation time for the fire drill held on 2/23/16 was 2 minutes and 40 second. The facility does not have an extended evacuation time specified in writing from a firesafety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | The fire drill in question occurred on 2/23/2016 Potential environmental barriers for safe exit from the SCC program, in case of fire were reviewed by the ACOO of Recovery Support and IDD Supervisor Marilyn Rauterkus on 2/25/2016. The SCC program area was inspected. During the review it was noted that the storage area for wheelchairs was under the stairs leading down from the upper floor. This location is across the program space from both exits from the facility. The program space was reconfigured to allow the wheelchairs to be stored in an area next to each exit. Following this change in in location for program wheelchairs all fire drills have been in compliance since the February 23, 2016 fire drill. As an additional measure to ensure the safety of all individuals, the local fire safety expert was contacted by the Director of IDD Day Programs on 3/6/3017. This person will determine a date and a time to come to the Chartiers Center Dormont location and evaluate the period time needed to safely evacuate the facility. If the time may be longer than the requirement of 2 ½ minutes, a formal letter will be issued by the fire safety expert specifying the time and retained by the Director of IDD Day Programs by 3/31/2017. |
03/13/2017
| Implemented |
| 2380.111(c)(5) | The two most recent Tuberculin skin testing for Individual #1 were completed 4/2/14 and 4/27/16. | 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. | It is noted that the primary care physician¿s office did not have the tuberculin protein available to administer the TB test when completing the physical for Individual #1 on 4/2/2016 and had to order more solution to complete the test. This made completing the test the day of the physical not possible and caused a delay in completing the test. The issue was reported to the program yet the program did not receive correspondence from the physician¿s office stating the cause of the delay for the individual¿s record. The Chartiers Center physical examination form letter which accompanies the agency¿s physical examination form was revised by the ACOO OF Recovery Support Services on 3/3/2017 to state that any problems with completing all required information and activities related to the individual¿s physical examination must be reported to the Director of IDD Day Programs by the end of the next business day following the individual¿s physical examination date. If deficiencies are noted, the ISC/Community Home Staff/Family will be contacted by the Director of IDD Day Programs the next business day to discuss a plan of remediation. Remediation will occur within the 10 days from the due date of the physical. On the day the physical form is received by the program, the Director for IDD Day Programs will review the physical form to ensure that all activities required of the physical examination process are completed. All documentation/correspondence regarding the issue(s) and physical examination will be maintained in the individual¿s record. This process was implemented on 3/6/2017. |
03/13/2017
| Implemented |
| 2380.111(c)(10) | The physical examination completed 1/31/17 for Individual #2 did not include medical information pertinent to diagnosis and treatment in case of emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The most recent physical examination form for Individual #2 was faxed to her primary care physician¿s office to be amended to include medical information pertinent to diagnosis and treatment in case of emergency by the Director of IDD Day Programs on 3/6/2017. The physician¿s office marked ¿N/A¿ on the line that reads ¿medical information pertinent to diagnosis and treatment in case of emergency¿. The updated physical form was received and filed in the individual¿s record on 3/8/2017. The Chartiers Center physical examination form letter that accompanies the physical evaluation form sent to the individual/Family/Community Home Staff was revised on 3/3/2017 to read that any problems with completing all required information and activities related to the physical examination must be reported to the Director of IDD Day Programs by the end of the next business day following the individual¿s physical examination date. The letter also states that the Chartiers Center created physical examination form must be used for documentation of the individual¿s physical and a requirement that all areas of the physical form including medical information pertinent to diagnosis and treatment in case of emergency are to be completed. If an area where information is to be provided is non-applicable to the individual, it is requested via the letter that the physician state "non-applicable¿ on the appropriate line on the form. The secretary of IDD Day Programs will review all records using the census lists for the ETC and SCC programs as a guide working through the list alphabetically by last name. She will review each individual¿s physical forms for missing information. When areas of information are discovered to be missing, she will fax a request to the physicians' office requesting the missing information be documented on the form. The secretary will maintain a folder of all faxed requests. When the information is complete she will denote on the request the date and time the information was received. This will be completed by 3/17/17. In instances where 1 week, has elapsed and the information has not yet been received, she will send a second request via fax to the physician's office. Once all physical information is complete, the secretary will let the Director of IDD Day Programs know via email that all actionable items have been addressed with regard to individual physical forms. The Director of IDD Day Programs will then do a random audit of 10% of the individuals' records in the ETC and SCC as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day. The review of physical forms will be completed by 3/31/2017. Beginning, April 1, 2017, at the end of each 3 month period the Director of IDD Day Programs will review a 10% sample of program individuals to ensure compliance with the regulations regarding physical examinations. Any deficiencies noted will be forwarded within one business day to the IDD Day Programs who will contact the physician¿s office to have the physical form amended. |
03/13/2017
| Implemented |
| 2380.111(c)(11) | The physical examination completed 2/6/17 for Individual #4 did not include special instructions for the individual's diet. This section was left blank. | The physical examination shall include: Special instructions for an individual's diet. | The most recent physical examination form for Individual #4 was faxed to her primary care physician¿s office to be amended to include special instructions regarding the individual¿s diet by the Director of IDD Day Programs on 3/6/2017. The physician checked the box on the form that states ¿no restrictions¿ in the dietary section. The updated physical form was received and filed in the individual¿s record on 3/08/2017. The Chartiers Center physical examination form letter that accompanies the physical evaluation form sent to the individual/Family/Community Home Staff was revised on 3/3/2017 to read that any problems with completing all required information and activities related to the physical examination must be reported to the Director of IDD Day Programs by the end of the next business day following the individual¿s physical examination date. The letter also states that the Chartiers Center created physical examination form must be used for documentation of the individual¿s physical and a requirement that all areas of the physical form including special instructions related to the individual¿s diet be completed. If an area where information is to be provided is non-applicable to the individual, it is requested via the letter that the physician state "non-applicable¿ or ¿N/A¿ on the appropriate line on the form. The secretary of IDD Day Programs will review all records using the census lists for the ETC and SCC programs as a guide working through the list alphabetically by last name. She will review each individual¿s physical forms for missing information. This will be completed by 3/17/2017. When areas of information are discovered to be missing, she will fax a request to the physicians' office requesting the missing information be documented on the form. The secretary will maintain a folder of all faxed requests. When the information is complete she will denote on the request the date and time the information was received. In instances where 1 week, has elapsed and the information has not yet been received, she will send a second request via fax to the physician's office. Once all physical information is complete, the secretary will let the Director of IDD Day Programs know via email that all actionable items have been addressed with regard to individual physical forms. The Director of IDD Day Programs will then do a random audit of 10% of the individuals' records in the ETC and SCC as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day. The review of physical forms will be completed by 3/31/2017. Beginning, April 1, 2017, at the end of each 3 month period, the Director of IDD Day Programs will review a 10% sample of program individuals to ensure compliance with the regulations regarding physical examinations. Any deficiencies noted will be forwarded within one business day to the IDD Day Programs secretary who will contact the physician¿s office to have the physical form amended within 3 business days. |
03/13/2017
| Implemented |
| 2380.173(1)(ii) | The records for Individual #2 and Individual #3 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. | Information was added to the line to the IDD identification form for Individuals #2 and #3 on 3/6/2017 by the Director of IDD Day Programs. It is noted that the identification form was recently revised with the admission packet and that the line containing identifying marks was mistakenly omitted. The secretary of IDD Day Programs revised the form on 3/8/2017 to once again include a line for identifying marks. The IDD Day Programs secretary reviewed all emergency profile forms for individuals in both Employment training Center (ETC) and Senior Community Center (SCC) to ensure that information pertaining to identifying marks was present, correcting any deficient forms. This was completed on 3/9/2017. The Director of IDD Day Programs will do a random audit of 10% of the individuals' records in the ETC and SCC as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify by the next business day. The review of identification forms will be completed by 3/31/2017. |
03/13/2017
| Implemented |
| 2380.181(a) | The two most recent assessments for Individual #5 were completed 9/16/15 and 10/19/16. | 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. | All annual assessment dates were reviewed for program individuals on 3/7/2017. There were no missing annual assessments. A tracking form was devised by the Director of IDD Day Programs and implemented by the Program Specialist on 3/7/2017. This assessment tracking form lists the individuals on the Program Specialists caseload and contains each individual¿s assessment annual due by date. This tracking form will be available on the terminal server P:/Drive which all Program Specialists and the Director of IDD Day Programs has shared access. The Director of IDD Day Programs will review with each Program Specialist at the beginning of each month the assessments that are to be completed within the next 30 days and when they are due. The Director of IDD Day Programs will monitor completion of each assessment and sign them as second signature to the Program Specialist¿s initial signature in the electronic health record. The tracking form will be revised with future dates by the Director of IDD Day Programs after each assessment is completed. Ongoing, beginning April 1, 2017, on a quarterly basis the Director of IDD Day Programs will audit a 10% sample of individual records to ensure that functional assessments are being completed as expected according to regulation. |
03/13/2017
| Implemented |
| 2380.186(d) | The program specialist did not provide the ISP review documentation for the review periods 2/8/16 to 5/7/16, 5/8/16 to 8/7/16, 8/8/16 to 11/7/16 and 11/8/16 to 2/7/16 for Individual #5 to the entire plan team members including the SC and residential provider. | 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 assigned Program Specialist mailed each quarterly review for Individual #5 to both the ISC and The Residential Supervisor on 3/8/2017. The assigned Program Specialist retained all documentation in the record of Individual #5. It is noted that documentation was not appropriately maintained in this individual¿s file that specify that the ISC or plan lead were provided the information on plan reviews. A program process was implemented to ensure all individual records meet this regulation. At the time of the ISP meetings, the assigned Program Specialists will require a ¿yes¿ or ¿no¿ on the signature form which serves as the declination form for ISP correspondence. It is acknowledged that the ISC will always receive quarterly reviews. A correspondence tracking form was devised on 3/9/2017 by the ACOO of Recovery Support Services and Director of IDD Day Programs to assist the Program Specialist in meeting the requirement for providing quarterly review documentation to the parties who have elected to receive it. After the Program Specialist completes the review meeting and documents the review, it will be sent to the Director of IDD Day Programs who will review and sign off on the plan review. This process will occur within two business days. Using the date of the plan review the Director for IDD Day Programs will alert the secretary of IDD Day Programs who will prepare the review and cover letter for each party designated to receive it. The copies of the plan review documentation and cover letters will be presented for the Program Specialist¿s review and signature. The documents will be mailed to each party within 14 days from the date of the plan review. The review date/mailing date will be documented on the tracking form for the individual. This form will be maintained on the P:/Drive which all Program Specialists, the IDD Day Program secretary and IDD Day Program Director have access. A copy of all mailed documents will be retained by the secretary in the individual¿s file. This process was implemented on 3/9/2017. |
03/13/2017
| Implemented |
|
|
|
SIN-00089904
|
Renewal
|
02/16/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(f) | Direct Service Worker #1 was trained in fire safety on 3/26/14 and then again on 6/23/15. Direct Service Worker #2 most recent fire safety training was 11/24/14. | Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f). | Direct Service Worker #2 completed his fire safety agency approved training on 2/25/16. A training course completion list was printed from the Relias electronic training management system that shows all completion dates for fire safety dates. This will be used to specify deadline dates for when a fire safety training is due for each staff. This will be tracked by the IDD Site Supervisor, who will ensure all fire safety trainings are completed by staff prior to their annual anniversary dates.[Immediately, COO will develop and implement a tracking system for annual trainings including fire safety. COO will train the site supervisor on the tracking system. COO will review the tracking system and trainings at least twice a year to ensure timely completion of staff trainings. Immediately, COO or designated staff will review all staff fire safety trainings to ensure they were completed timely and staff will be trained in fire safety if needed. Documentation of trainings and reviews shall be kept.(AS 3/1/16)] |
02/29/2016
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination, completed 10/12/15, did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A request for medical information pertinent to diagnosis and treatment in case of an emergency was submitted on 2/24/16 to Individual #1 primary care physician's office. The physician was asked to complete the Chartiers Center physical form and return it to the ETC program via fax. The updated information was received on 2/25/16 and will be included with the current physical form in the individual's record. The letter that accompanies the physical form for requests for annual physicals was revised to specify that individuals, families and care providers must use the Chartiers Center created physical form for documentation of physicals. Additionally, the letter requests that all areas of the physical form including medical information pertinent to diagnosis and treatment in case of emergency are completed. If an area where information is to be provided is non-applicable to the individual, it is requested that the physician state "N/A" on the form. The Chartiers ETC/SCC secretary will review all records using the census lists for the ETC and SCC programs as a guide working through the list alphabetically by last name. She will review each individual's physical forms for missing information. When areas of information are discovered to be missing, she will fax a request to the physicians' office requesting the missing information. The secretary will maintain a folder of all faxed requests. When the information is complete she will denote on the request the date and time the information was received. In instances where 2 weeks, have elapsed and the information has not yet been received, she will send a second request via fax to the physician's office. Once all physical information is complete, the secretary will let the IDD Site Supervisor know via email that all actionable items have been addressed with regard to individual physical forms. The IDD Site Supervisor will then do a random audit of 10% of the individuals' records in the ETC and SCC as a compliance review. Any deficient areas discovered will be forwarded to the secretary to rectify. The review of physical forms will be completed by 3/29/16. |
02/29/2016
| Implemented |
| 2380.173(1)(ii) | The records for Individual #1 and Individual #2 did not include color of hair, color of eyes and 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. | Individuals #1 and #2 referenced in the violation description had the missing information pertaining to color of hair, color of eyes and identifying marks added to the face sheets of their records on 2/18/2016 . A review process was set up to inspect the records of all clients face sheets to ensure that this information is included. Each Program Specialist for the ETC and SCC programs will be required to review the individuals' face sheets on their respective caseloads. This will be done by printing out their caseload from the Qualifacts electronic health record and using it is as a checklist working down from top to bottom in alphabetical order. The Program Specialist will include any missing information that is missing pertaining to this regulation. Once the review is completed and any missing information added, they will place a check mark next to the persons name. Once the checklist is completed they will sign and date the bottom of the page. The checklist will then be turned into the IDD Site Supervisor for review. A ten percent random sample of each Program Specialists caseload lists will then be reviewed by the IDD Site Supervisor as an additional compliance check. The review of records will be completed by 3/29/16. |
02/29/2016
| Implemented |
| 2380.173(1)(iv) | The record for Individual #1 did not include religious affilitation. | Each individual's record must include the following information: Personal information including: Religious affiliation. | Individual #1 in the violation description had the missing information pertaining to religion added to the face sheets of his record on 2/18/2016 . A review process was set up to inspect the records of all clients face sheets to ensure that this information is included. Each Program Specialist for the ETC and SCC programs will be required to review the individuals' face sheets on their respective caseloads. This will be done by printing out their caseload from the Qualifacts electronic health record and using it is as a checklist working down from top to bottom in alphabetical order. The Program Specialist will include any missing information that is missing pertaining to this regulation. Once the review is completed and any missing information added, they will place a check mark next to the persons name. Once the checklist is completed they will sign and date the bottom of the page. The checklist will then be turned into the IDD Site Supervisor for review. A ten percent random sample of each Program Specialists caseload lists will then be reviewed by the IDD Site Supervisor as an additional compliance check. This review of records will be completed by 3/29/16 |
02/29/2016
| Implemented |
| 2380.186(a) | The ISP was reviewed with Individual #1 on 9/29/15 and then again on 1/19/16.[Repeat violation-2/13/15] | 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. | The following amendment will be done to the current ISP review tracking process previous implemented by the ECT/SCC programs. When a ISP is fully signed, the ETC/SCC secretary will count 90 days ahead on the calendar and determine a next review date. This will be maintained in the ISP tracking spreadsheet used for the programs. The ETC/SCC will retain the spreadsheet and ensure that all future review dates are included in a column marked Review Deadline. It will be the responsibility for the secretary to update the spreadsheet in real time and advise the Program Specialists and IDD Site Supervisor a month prior to review dates coming due. It will be the expectation that all signatures will be obtained prior to that date. It was also noted that though the individuals of the program sign their ISP they are often not dating their signature. This can create confusion with regard to when they actually reviewed the provided copy of their ISP. The ETC/SCC program will implement a practice where the individual includes the date with their signature or it is date stamped. This practice will be implemented in conjunction with the revision to the ISP review tracking process. The IDD Site Supervisor will train the Program Specialists and IDD Secretary of the changes to the ISP review and tracking process. This revision to the ISP review process will be fully implemented by 3/29/2016.[COO or designated staff person will review the tracking spreadsheet at least quarterly to ensure timely completion of ISP reviews and accurate documentation in the tracking system. COO or designated staff person will review a 10% sample of ISP reviews at least quarterly to ensure timely completion. Documentation of reviews shall be kept. (AS 3/1/1/6)] |
02/29/2016
| Implemented |
|
|
|
SIN-00071085
|
Renewal
|
02/13/2015
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.173(7) | Individual #2's record did not include a copy of the current ISP. The ISP in the record was dated 7/1/2013 to 6/30/2014 and did not include information on the individual's admission to the day program on 4-3-14. "Repeated Violation - 3/5/14" | Each individual¿s record must include the following information: A copy of the current ISP. | No individual will be admitted to the Chartiers Day Program without Chartiers Center being an authorized day program provider, as evidenced on the ISP. A copy of the current ISP will be included in each individual's record on an annual basis, at a minimum. If updates or revisions have occurred, they will be included as well. This will be based on notification that the ISP has been approved (receipt of the signature page from the Supports Coordinator). The responsible persons will be the IDD Secretary and the IDD Day Program Manager. The effective date will be 3/19/15. |
03/19/2015
| Implemented |
| 2380.181(a) | Individual #3's most recent assessment was completed on 7-10-14. The previous assessment was completed on 5-24-13. | 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 functional assessment will be completed for each individual, within 60 days after admission to the facility and updated annually thereafter. Retraining was provided to all program specialists on 3/19/15, which included ARUD dates, Service Plans, Functional Assessments, and submission requirements. A copy of the training signature page will be forwarded to you. The change is effective as of 3/19/15. A new tracking system/ongoing record review has ben established and will be monitored and updated by the day program manager and the COO of IDD Services, to ensure compliance. |
03/19/2015
| Implemented |
| 2380.181(f) | The assessment for Individual #3 dated 7/10/14 was not sent to the individual's team.
The assessment for Individual #4 dated 9/29/14 was sent to the plan team and SC on 10/2/14 for an ISP meeting held on 10/30/14. | 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 functional assessment will be sent to the team members at least 30 days prior to the ISP meeting. All program specialists were retrained on 3/19/15, which included ARUD dates, Service Plans, Functional Assessments, and submission requirements. A copy of the training signature page will be forwarded to you. The change is effective as of 3/19/15. A new tracking system/ongoing record review has been established and will be monitored and updated by the day program manager and the COO of IDD Services, to ensure compliance. |
03/19/2015
| Implemented |
| 2380.186(a) | The ISP review for Individual #4 dated 7/29/14 to 10/28/14 was signed and dated by the Program Specialist on 12/18/14. "Repeated Violation - 3/5/14" | 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. | The program specialist will complete and sign an ISP review every three months. All program specialists were retrained on 3/19/15, which included ARUD dates, Service Plans (ISP reviews), Functional Assessments, and submission requirements. A copy of the training signature page will be forwarded to you. The change is effective as of 3/19/15. A new tracking system/ongoing record review has been established and will be monitored and updated by the day program manager and the COO of IDD Services, to ensure compliance. |
03/19/2015
| Implemented |
| 2380.186(b) | The ISP review for Individual #1 dated 7/1/14 to 9/30/14 was signed by the Program Specialist on 12/18/14 and by the individual on 1/16/15.
The ISP review for Individual #1 dated 4/1/14 to 6/30/14 was signed by the Program Specialist on 8/26/14 and by the individual on 9/8/14.
The ISP review for Individual #1 dated 1/1/14 to 4/1/14 was signed by the Program Specialist on 7/30/14 and by the individual on 9/8/14.
The ISP review for Individual #4 dated 7/29/14 to 10/28/14 was signed and dated by the individual on 1/29/15. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The ISP review signature sheet will be signed and dated by the program specialist and individual upon completion of the ISP review. All program specialists were retrained on 3/19/15, which included ARUD dates, Service Plans (ISP Reviews), Functional Assessments, and submission requirements. A copy of the trainng signature page will be forwarded to you. The change is effective as of 3/19/15. A new tracking system/ongoing record review has been established and will be monitored and updated by the day program manager and the COO of IDD Services, to ensure compliance. |
03/19/2015
| Implemented |
| 2380.186(d) | The following ISP Reviews for Individual #1 were not sent to the team and the SC within 30 days of the ISP review meeting: 10/1/14 to 12/6/14 was sent on 1/23/15; 7/1/14 to 9/30/14 was sent on 1/21/15; 4/1/14 to 6/30/14 was sent on 9/8/14; 1/1/14 to 4/1/14 was sent 9/8/14.
The following ISP Reviews for Individual #2 were not sent to the team and the SC within 30 days of the ISP review meeting: 8/2/14 to 11/1/14 was sent on 12/9/14; 6/12/14 to 8/1/14 was sent on 9/29/14.
| 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 ISP review will be sent to the team within 30 days of the ISP review. All program specialists were retrained on 3/19/15, which included ARUD dates, Service Plans (ISP Reviews), Functional Assessments, and submission requirements. A copy of the training page will be forwarded to you. The change is effective as of 3/19/15. A new tracking system/ongoing record review has been established and will be monitored and updated by the day program manager and the COO of IDD Services, to ensure compliance. |
03/19/2015
| Implemented |
|
|
|
SIN-00051729
|
Renewal
|
03/05/2014
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.59(b) | The hot water temperature at the sink in the upstairs women's bathroom was 141.2 degrees at 10:40am. | (b) Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The hot water temperatures will not exceed 120 degrees. The water temperatures will be taken on a daily basis and if the temperature is at or above 120 degrees, the water heater temperature will be lowered. A daily water temperature log will be maintained at the site by the program staff assigned. If he/she is not available, the site supervisor will assume that responsibility. The water temperature will be taken at various locations throughout the facility. |
03/15/2014
| Implemented |
| 2380.62 | The telephone next to the fireplace in the upstairs program area does not have the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center on or by the telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line. | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are posted by each telephone in the facility with an outside line. This was completed by the IDD secretaary and site supervisor on 2/24/14. |
03/15/2014
| Implemented |
| 2380.89(c) | The written fire drill record from 7/12/12 to 1/31/14 did not indicate the exit routes used. "Regular" or "Alternate" was written on the record under "Exit Routes Taken", an explanation of actual exits was not indicated on the fire drill record. | (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. | The explanation for "regular" and "alternate" exit routes will be reflected and maintained by means of a key in the fire drill record. The site supervisor will oversee the implementation of this updated fire drill record and all staff will be trained on the updated fire drill record and will sign for having received the training. |
03/15/2014
| Implemented |
| 2380.173(7) | The most recent ISP for Individual #1 in the record had an Annual Review Update Date of 11/13/12. | (7) A copy of the current ISP. | A copy of current ISPs will be maintained in the client record. The site supervisor will monitor HCSIS to determine when approved plans are available, then print, review, and have staff review prior to enclosure in the client record. The ISP for Individual #1 was printed and then distributed for review on 2/24/14. |
03/15/2014
| Implemented |
| 2380.186(a) | The quarterly reviews from January, 2013 to March, 2013 and from April, 2013 to June, 2013 for Individual #2 were not completed and signed by the program specialist until 2/19/14. The quarterly review for July, 2013 to September, 2013 for Individual #1 was not completed as of 2/24/14. | (a) 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. | The program specialist will complete an ISP review of the services and outcomes specific to Chartiers on a quarterly basis, at a minimun. The site supervisor will ensure the reviews are completed as required. The program specialist will maintain a list of the due dates for the quarterlies, and maintain the data for the quarterlies. The site supervisors will track to ensure the quarterlies are completed. The program specialists and the site supervisors will be trained on the updated internal/external communication policy for Chartiers and will sign off for having received this training. |
03/15/2014
| Implemented |
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SIN-00169027
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Renewal
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01/09/2020
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Compliant - Finalized
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