| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.91(a) | REPEAT from 10/1/2019 annual inspection: There are no records maintained that all fire safety training requirements defined in Pa code 55 chapter 2380.91(a) were reviewed with individuals during their annual fire safety trainings. The agency reported that individuals receive training via a video created by the York county fire chief. However, the fire safety training video does not include information/training on the evacuation procedures specific to the facility, individual and staff responsibilities during fire drills at the facility, and smoking safety procedures at the facility. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | Program Specialists are responsible to ensure individuals receive 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 and have been retrained in such (Att A). |
04/28/2021
| Implemented |
| 2380.111(c)(3) | REPEAT from 10/1/19 annual inspection: Individual #2's current, 6/29/2020 physical examination record did not include their immunization or record of their last Tetanus or Diphtheria immunization as recommended by the Center for Disease Control. The field for this information was left blank on the examination record. There wasn't record of any additional documents attached to the physical examination record that included said information. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Program Specialists are responsible to ensure physical examinations for individuals contain all information required per 2380.111 c, including record of all immunizations and have been trained in such (Att A).
Attached is an addendum correcting Individual #2s current physical (Att C). |
06/01/2021
| Implemented |
| 2380.111(c)(10) | REPEAT from 10/1/19 annual inspection: Individual #2's current, 6/29/2020 physical examination record did not include their information pertinent to diagnosis and treatment in case of an emergency. The field on the record indicated to find this information, one should review information in an emergency manual (that wasn't attached or included in the record) and review individual specific information on an electronic system which day program staff or emergency personnel cannot access. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialists are responsible to ensure physical examinations for individuals contain all information required per 2380.111 c, including medical information pertinent to diagnosis and treatment in case of an emergency and have been trained in such (Att A).
Attached is an addendum correcting Individual #2s current physical (Att C). |
06/01/2021
| Implemented |
| 2380.171(b)(3) | Individual #1's record does not include specific details (the name, address, and telephone number, or clarifying information) of the person able to give consent for emergency medical treatment. The individual's record states that for medical consent for day to day medical issues/minor medical emergency's one is to contact Staff person #2, #5 or designee but does not include their address or telephone number or who the designee would be. The individual's record also states that for medical consent life threatening medical emergencies, one is to contact the individual's residential director, the individual's mother, or designee but does not include the residential director's address and telephone number or who the designee might be. Individual #1's individual support plan states that their mother is the person who will make necessary medical decisions which does not allow for the option to contact another person like the individual's record indicates.
Individual #2's record also did not clarify the name, address and telephone number of the person able to give consent for emergency medical treatment. The individual's individual plan states that their residential director is to provide consent for the individual. However, the individual's identification form in their record states Staff person #2, Staff person #5, or designee are to be contacted for medical consent for day to day medical issues/minor medical emergencies. The individual's record didn't include their address or telephone number. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Program Specialists are responsible to ensure an individuals record contains accurate and complete information regarding emergency information and consent and have been retrained in such (Att A).
The individuals 1 and 2s face sheets have been corrected to include the information directly from their ISPs (Atts E 1 and 2). |
06/26/2021
| Implemented |
| 2380.172(b) | Individual #3's medication administration record (mar) for December, listed that it was charting for medication administrations in December 2020. However, 2020 was crossed off and 2019 was written next to it. The name of the staff person making this change and the date it was changed was never recorded in the individual's record.
Additionally, another mar for Individual #3 listed that it was charting for medication administration from 1/1/2020 -- 1/21/2020. However, this date range was crossed out and "December '19" was written above this. The name of the staff person making this change and the date it was changed was never recorded in the individual's record. | Entries in an individual¿s record shall be legible, dated and signed by the person making the entry. | Program Specialists are responsible for ensuring all entries in an individuals record are legible and have a full signature and date and have been retrained in such (Att A). This includes Medication Administration Records.
Attached is a case note entry made since the current licensing inspection showing the proper procedure (Att F). |
04/28/2021
| Implemented |
| 2380.181(e)(10) | Individual #2's current, 9/8/2020 assessment does not include an updated lifetime medical history. The lifetime medical history document attached to their 2020 assessment, was last updated on 8/14/2019, over a year prior to the assessment completion. There is also contradicting information in the individual's assessment regarding their medical history with choking concerns. A choking plan is attached to the assessment indicating the individual is a choking risk, the assessment states the individual is a choking risk and the assessment also states the individual isn't a choking risk. | The assessment must include the following information: A lifetime medical history. | Program Specialists are responsible for ensuring an individuals assessment contains all relevant and required information, including a complete and accurate lifetime medical history and have been retrained in such (Att A).
Attached is Individual #2s assessment addendum correcting his Lifetime Medical History (Att G). |
06/01/2021
| Implemented |
| 2380.181(e)(12) | Individual #2's current, 9/8/2020 assessment does not include recommendations for specific training, vocational programming and competitive community-integrated employment. The assessment states the individual will continue to work on their current goal upon return to program but doesn't include the goal. The assessment also states that if the individual would like to pursue vocational programming this will be explored, and the individual isn't interested in employment at this time. The agency's assessment of the recommendations for the individual in vocational programming and employment were not included. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Program Specialists are responsible for ensuring an individuals assessment contains all relevant and required information, including recommendations for specific areas of training, vocational programming and competitive community-integrated employment and have been retrained in such (Att A).
Attached is Individual #2s assessment addendum correcting this section of his assessment (Att G). |
06/01/2021
| Implemented |
| 2380.21(u) | The Department issued updated, regulatory rights effective, 2/3/2020, that included individuals' rights they need informed of. At the time of the 4/12/2021 inspection, the agency never informed Individuals #1 and #2 of their regulatory rights defined in PA Code 55 chapter 2380.21(a)-(t). | 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. | Program Specialists are responsible for ensuring all individuals have been informed of their rights and the reporting process for rights violations and have been retrained in such.
The individual rights and reporting process had been added to the Individual Handbook (Att I). |
04/28/2021
| Implemented |
| 2380.126(a)(2) | Individual #1's medication administration records from March 2020 to current, March 2021, did not include the name of the prescriber for their psychotropic medication administered to them at program. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Program Specialists are responsible to ensure MARs contain all information needed per Department regulations, including name of the prescriber, and have been re-trained in such (Att A). |
04/28/2021
| Implemented |
| 2380.126(b) | Staff person #3 administered medication to Individual #3 on 2/4-7/20, 2/10-13/20, 2/18-20/20,and 2/24-27/20 but didn't record their name on the individual's medication administration record (mar) at the time the medication was administered. The staff did not record their name and corresponding initials on the mar until 4/15/2021 after the Department representative notified the agency that this information was missing. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | - Program Specialists are responsible to ensure MARs contain all information needed per Department regulations, including signature and corresponding initials of staff administering on the back of the MAR, and have been re-trained in such (Att A). |
04/28/2021
| Implemented |
| 2380.129(a) | REPEAT from 10/1/19 annual inspection: Staff person #3 has been administering medications to individuals in the facility since prior to 2019. There are no records maintained that they received and completed the Department's approved medication administration training annually. Staff person #3 received and passed the training on 8/3/18 and not again until 12/4/2020.
Staff person #4 has been administering medications to individuals in the facility since prior to 2019. They received and passed the Department's medication administration training on 11/11/19 and not again until 1/28/21, outside the annual time frame requirement.
Staff person #1 had a medication administration trainer certify them on 5/30/2019 to administer medications to individuals at the facility and not again until 12/4/2020, outside the annual time frame. Additionally, Staff person #1's 5/30/2019 medication administration training only included one, out of the two required, medication administration record (mar) reviews. The staff's 2019 medication administration training record indicates that mar reviews were completed on 5/30/2018 and 9/17/2018. The 5/30/2018 mar review fell within the staff's 2018 medication administration training year. Thus, the staff's 2019 medication administration training was incomplete. | 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). | This is the same Plan of Correction provided to the Department following a Residential Monitoring where it was discovered staff were not in compliance:
An audit of all medication training records was completed by HR Administrative Assistants as of 12/11/2020. During the audit, any staff member who was not in compliance was immediately notified that he/she was not able to administer medications until their training was compliant. All staff members that did not have a valid medication administration certificate were retrained in the initial medication administration training. The purpose of the audit was to check the records of every staff member with responsibility for administering medications to ensure that there were not additional staff out of compliance beyond the 19 identified during the licensing inspection on 11/9/2020. A second audit of all medication training records was completed by (Quality Manager) and (QM Coordinator/Compliance Officer). This audit was finalized on 2/28/2021. |
04/28/2021
| Implemented |
| 2380.186 | REPEAT from 10/1/19 annual inspection: Individual #1's current assessment and individual support plan include a seizure protocol for staff to implement if the individual has a seizure at program. The seizure plan states that when Individual #1 begins to have a seizure the individual, if able, or staff are to swipe the individual's magnet over the individual's chest where the Vagus Nerve Stimulation (VNS) device is implanted to assist with stopping a seizure. Agency staff documented that Individual #1 had seizures at program on 2/3/2020, 12/23/2019, and two on 10/3/2019. There are no records maintained that the magnet was used at any point during those seizures.
Additionally, Individual #1's seizure plan states that after the magnet is swiped over the VNS implanted device and they continue to seize, staff will wait it out. Then only after 5 minutes will staff contact 911 and the individual's residential provider. There are no records maintained that the individual's physician approves of staff to continue to let the individual seizure for 5 minutes without any other intervention strategies. | The facility shall implement the individual plan, including revisions. | Program Specialists are responsible to ensure an individuals plan is implemented as written and have been retrained in such (Att A).
Attached is Individual #1s Assessment Addendum and request to correct the ISP designating the proper way to support her during a seizure as well as a corrected seizure protocol with physician orders (Att J).
Attached also is the amended seizure report to include use of a VNS (Att K) |
04/28/2021
| Implemented |