| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(a) | Staff #3 was hired as a program specialist on 2/23/17 and Staff #1 was transferred to become a program specialist on 5/1/17 and there is no documentation that they were trained on their program specialist responsibilities covered under 33(b)(1)-(18). | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | Current staff have been trained .Appendix M for staff #3 and Appendix L for Staff #1
A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/30/2017
| Implemented |
| 2380.36(a) | There was no documentation to indicate that the agency provided Staff #1 orientation to the daily operations of the facility. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | Training has been provided. See Appendix L- training for staff #1 |
11/20/2017
| Implemented |
| 2380.36(d) | There was no documentation to indicate that the agency provided Staff #1 with orientation to program planning and implementation within 30 days of her hire date. | Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | This has been completed - Appendix L- training for staff #1 |
11/20/2017
| Implemented |
| 2380.53(a) | REPEAT from 9/26/16 renewal inspection: Some Individuals that attended the program, including Individuals #1 and #2, were assessed to be unsafe around poisonous materials. Comet and Spic and Span that both contained a label to contact poison control center were found unlocked and accessible in the closet in the woodworking room. The first aid kits in each room contained antiseptic that indicated to contact poison control center if ingested. The first aid kits were unlocked and accessible to individuals. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Appendix J- Daily environmental Checklist.
Administrative assistant will complete environmental walkthrough daily to ensure all chemicals remained locked up, and will utilize a checklist to ensure all areas are checked. Staff will be provided immediate feedback if any violations are noted. . |
12/30/2017
| Implemented |
| 2380.55(d) | There was a large trashcan, approximately 4 feet tall, in the kitchen, dining, and first aid areas that were not equipped with a lid or apparatus to keep the receptacle closed and covered | Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents. | This has been corrected. See Appendix C Picture |
12/30/2017
| Implemented |
| 2380.57 | The music room egress was not equipped with an operable light. | Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. | This has been corrected. Appendix H Picture |
11/20/2017
| Implemented |
| 2380.58(a) | The glass light enclosure located on the outside of the building by the music room egress, was detaching from the building structure and missing a few glass panels. | Floors, walls, ceilings and other surfaces shall be in good repair. | This has been corrected. See Appendix F Picture |
11/20/2017
| Implemented |
| 2380.62 | The numbers to the nearest hospital, police department, fire department, ambulance and poison control center were not posted or near the telephone in the flower room or the yarn room. All telephones in the facility, except for one, were not equipped with at least one or more of the emergency telephone numbers. | 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. | This has been corrected. see Appendix I
All phones updated with the following numbers:
CHILDLINE: 9-1-800-932-0313
DELCO CO. COSA 9-1-610-490-1300
County office of services for Aging
CHESTER CO. COSA 9-1-610-344-6350
AMBULANCE/FIRE 9-911
BERWYN FIRE CO. 9-1-610-644-6050
PAOLI HOSPITAL 9-1-484-565-1000
POISON CONTROL 9-1-800-222-1222 |
11/20/2017
| Implemented |
| 2380.70(b) | The music room that doubled as the first aid area was not equipped with a blanket, pillow, or cot. The cot was kept locked, outside the facility in a shed. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | This has been corrected. See Appendix G. |
11/20/2017
| Implemented |
| 2380.82 | There was a patio chair located in front of the flower room French door egress, blocking the exit. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | This has been corrected. See Appendix D and E Picture |
12/30/2017
| Implemented |
| 2380.84 | The onsite fire safety inspection of the facility was conducted by a fire safety expert on 3/9/16 and not again until 4/3/17, outside the annual time frame. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | See Appendix K- Qware system- entered annually.
A new system has been put in place for preventative maintenance to ensure that the fire safety inspection occurs within the required time frame annually by a fire safety expert |
12/30/2017
| Implemented |
| 2380.111(c)(10) | Individual #2¿s 11/28/16 physical examination form did not include information pertinent to diagnosis in case of an emergency. The field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | See Appendix R for nursing training |
12/30/2017
| Implemented |
| 2380.124(a) | Individual #2s record contained a nursing note that indicated on 3/20/17 he/she was administered ii Tylenol at 11:40am for c/o headache with only the initials KG recorded for the person responsible for administering the medication. The medication log did not indicate a dosage that was administered or the name of the staff that administered the medication, only their initials was documented in the record.' | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | this medication error occurred during residential hours. The residential team will develop a plan of corrections. |
12/30/2017
| Implemented |
| 2380.125 | Individual #4's Tears Natuale-eye drops were not administered at noon on 8/6/17. The medication error and follow up information was not in his/her record. | Documentation of medication errors and follow-up action taken shall be kept. | This medication error occurred on a Sunday during residential hours, and not at the 2380 program. The residential team will develop a plan of correction. |
12/30/2017
| Implemented |
| 2380.127(b) | Staff #5 indicated on Individual #4's August 2017 medication administration record at 11:51am on 8/6/17 that Individual #4 Tears Natuale-eye drops were not administered at noon as prescribed due to the medication not being available. | Prescription medications and injections shall be administered according to the directions specified on the prescription. | This medication error occurred on a Sunday during residential hours, and not at the 2380 program. The residential team will develop a plan of correction. |
12/30/2017
| Implemented |
| 2380.128(a) | Staff #1 has been passing medications and she was never certified by a medication trainer with a certification completion date of when she could start passing medications. The student medication training practicum sheet was blank for the 4 required observations, whether the trainer was passing or not passing her, and a date of certification. | A staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Appendix O All four observations were completed for the medication certified staff member. The cover sheet was not completed by the trainer. . A trainer will fill out the Coversheet. |
12/30/2017
| Implemented |
| 2380.132(5) | Individuals attend the program for at least 6 hours per day and the facility does not provide a nutritional snack. | If the facility provides or arranges for meals for individuals, the following requirements apply: At least one complete meal shall be provided if the individual is at the facility for 4 or more hours. If an individual is at the facility for more than 6 hours, a nutritional snack shall also be provided. | A nutritional snack is now available and will be available ongoing. |
11/20/2017
| Implemented |
| 2380.173(9) | Individual #2's record indicated that the President/CEO of Melmarks or the designee will give consent for emergency medical treatment. However his/her Individual Support Plan (ISP) indicated that Individual #2's mother or sister will sign for medical treatment in the event of an emergency. Individual #2's identification sheet indicated supervision: melmarks campus: 15 minutes, day program common areas: 30 minutes, day program program room: 30 minutes, transitions outside/uneven ground: 15 minutes, van: independent, bathrooms: independent. His/Her ISP indicated 1:6 ratio. His/Her assessment indicated visual supervision at all times. | Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Additionally, the record indicates that the President/CEO or designee will make decisions ONLY IF the guardian is not able to be reached after reasonable attempts in an emergency situation. This does not usurp the guardian's decision-making, but is only in effect if the guardian is not reachable. |
12/30/2017
| Implemented |
| 2380.176(a) | Individual #5 had access to Individuals #3 and #6 personal information that included diagnosis, date of birth, medical history, contact information, etc. as Individual #5 was carrying this information around the program at the time of inspection so staff could review and sign the documents that they were trained on Individuals #3 and #6 personal information. Individual records were unlocked and accessible to all individuals in the program in every room of the facility. The records that were accessible included behavior support plans, Individual Support Plans, assessments, physicals, outcome data, etc. | Individual records shall be kept locked when they are unattended. | All staff in the Meadows program have been retrained on HIPPA practices. See Appendix N. All staff will continue to be trained upon hire and annually, and will receive immediate feedback is any violations are observed. |
12/30/2017
| Implemented |
| 2380.181(a) | REPEAT from 9/26/16 renewal inspection: Individual #1's assessment was completed 9/15/16 and not again until 10/2/17. | 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 comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/30/2017
| Implemented |
| 2380.181(e)(4) | Individual #2's 2/27/17 assessment did not contain an assessment of his/her need for supervision in the community. His/Her assessment only indicated he/she required very close supervision when in the community but it did not explain if very close was monitoring every few minutes, arm's length, visual, hearing, etc. His/Her assessment also indicated that he/she received visual supervision when first starting meadows day program but this will be adjusted to allow a greater degree of independence. The assessment did not indicate if his/her supervision level was adjusted. | The assessment must include the following information: The individual's need for supervision. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B
Individual #2's assessment was updated - see Appendix S |
12/30/2017
| Implemented |
| 2380.181(e)(7) | Individual #4's 7/24/17 assessment did not include if he/she could move away safely from heat sources. | The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B |
12/30/2017
| Implemented |
| 2380.181(e)(10) | Individual #2's 2/27/17 assessment did not include a lifetime medical history that was attached to the assessment. Individual #1's 10/2/17 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B |
12/30/2017
| Implemented |
| 2380.181(e)(13)(i) | Individual #4's 7/24/17 assessment did not include progress and growth in health. The assessment was verbatim to his/her 9/6/16 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B |
12/30/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's 10/2/17 assessment and Individual #4's 7/24/17 assessment did not include progress and growth in recreation. Their 2017 assessments were verbatim to their 2016 assessments. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B |
12/30/2017
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's 10/2/17 assessment and Individual #4's 7/24/17 assessment did not include progress and growth in recreation. Their 2017 assessments were verbatim to their 2016 assessments. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B |
12/30/2017
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's 10/2/17 assessment and Individual #4's 7/24/17 assessment did not include progress and growth in community integration. Their 2017 assessments were verbatim to their 2016 assessments. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B |
12/30/2017
| Implemented |
| 2380.181(e)(14) | REPEAT from 9/26/16 renewal inspection: Individual #4's 7/24/17 assessment did not include his/her ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The 2380 ISP Assessment has been update to ensure that all required areas will be assessed for all individuals. See Appendix B |
12/30/2017
| Implemented |
| 2380.181(f) | Individual #2's 2/27/17 assessment was not sent to team members until 9/28/17. Individual #2's record indicated that his/her assessment was only sent to his/her supports coordinator and his/her mother. However his/her team members consisted of his/her mother, supports coordinator, behavior support specialist, and Individual #2. Individual #1's 10/2/17 assessment was not provided to all team members. It was not sent to his/her behavior support person and speech therapist that are team members. | 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). | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/30/2017
| Implemented |
| 2380.183(3) | Individual #2's Individual Support Plan (ISP) did not include the method of evaluation used to determine progress towards his/her expected outcome of "friendships", sitting appropriately at the table, and informing staff when he/she is leaving the room. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
The SC fro individual #2 was notified to update the ISP and include the method of evaluation toward the outcome of "friendships." See Appendix P |
12/30/2017
| Implemented |
| 2380.183(4) | Individual #2's Individual Support Plan (ISP) did not indicate what his/her supervision needs were at the program. His/Her ISP only indicated that he/she started Melmark on 1/4/17 and attends the program from 8am-4pm with a 1:6 staffing ratio. His/Her assessment indicated that he/she required visual supervision at all times within the program. His/Her ISP did not include the type of supervision needed in the community; only supervised at all times. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Email sent to SC to update level of supervision in ISP - See Appendix P
Level of supervision updated in assessment - see Appendix S |
12/30/2017
| Implemented |
| 2380.183(5) | Individual #3's Individual Support Plan (ISP) did not include a protocol to address his/her social, emotional and environmental needs. His/Her record did include a protocol however it was not included in his/her ISP. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Communication was sent to the SC to add SEEN plan to ISP and a copy of the Plan was sent to the SC (See Appendix Q). |
12/30/2017
| Implemented |
| 2380.183(7)(i) | Individual #2's Individual Support Plan (ISP) did not indicate his/her potential to advance in vocational programming. His/her ISP only indicated that he/she used to work at a vocational workshop. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A).
Email was sent to the SC requesting the potential to advance be added to the ISP per the ISP assessment. (see Appendix P). |
12/30/2017
| Implemented |
| 2380.186(c)(2) | Individual #2's Individual Support Plan (ISP) reviews did not include a review of his/her community participation. The reviews indicated he/she did not complete any community participations this quarter however he/she had interaction with community members since his/her start date at the program. His/her behavior support plan and behaviors were not reviewed on his/her ISP reviews. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). Individual #2's behavior support goals and community participation will be reviewed regularly in the ISP updates moving forward. |
12/30/2017
| Implemented |
| 2380.186(d) | Individual #2's Individual Support Plan (ISP) reviews were not sent to team members 30 days after completion. His/Her 8/22/17 ISP review was sent to his/her supports coordinator and mother on 8/21/17, prior to completion with Individual #2 on 8/22/17. His/Her ISP reviews were not sent to his/her behavior support person and Individual #2 His/Her 5/22/17 ISP review was sent on 5/21/17 to only his/her mother and supports coordinator prior to it's completion on 5/21/17. | 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. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility (see Appendix A). |
12/31/2017
| Implemented |
| 2380.186(e) | Individual #2's program specialist did not offer Individual #2's behavior support person or Individual #2 the option to decline Individual #2's Individual Support Plan (ISP) review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | A comprehensive Program Specialist training will take place no later than December 31, 2017. The training will include all Program Specialist responsibilities and all pertinent regulations regarding programming and documentation in a 2380 facility, including notifying all the plan team members of the option to decline the ISP review (see Appendix A). |
12/31/2017
| Implemented |