| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed on 7/25/16 did not include a summary of corrections made or the date corrections were made. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The Program Specialist corrected the "Self-Inspection Tool" to include the score and the summary, see attachment #18.
Policy on the Self Assessment was developed, describing in detail the procedure for self-inspection and follow-up plan, attachment # 21.
Training conducted by the Program Specialist is documented on Attachment #22. |
01/06/2017
| Implemented |
| 6400.103 | The written emergency evacuation procedure did not include individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The program specialist updated the "Evacuation Plan" to include the distribution of duties, see attachment #12.
Staff were re-educated on the "Emergency Procedure Plan" attachment #11 and the "Evacuation Plan" attachment #12.
Documentation of retraining is Attachment #13.
Ongoing training will be conducted on hire and annually thereafter at mandatory in-service |
01/06/2017
| Implemented |
| 6400.112(h) | The fire drill records did not include if individuals evacuated to the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The program specialist revised the policy "Fire Drills" see Attachment #5.
The fire drill log was updated to include the meeting place, see Attachment #10.
The fire drill was completed on 12/9/2016 using the revised form. |
01/06/2017
| Implemented |
| 6400.113(a) | Individuals #1 and #2 were living at their residence at 12/1/15. They did not receive training in general fire safety until 9/3/16. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 home. | Who: The program specialist and director of human resources updated the policy on Fire Safety Training, Attachment #4, to include " Upon admission and annually every January".
What: Policy was revised.
When: Current resident was re-educated on fire safety training program. The training is documented in attachment #4.
The information presented to each resident is documented on Attachments #3 & 5.
Staff retrained on the resident fire safety training plan as documented on Attachment #6. |
01/06/2017
| Implemented |
| 6400.142(a) | Individual #1's record did not have documentation that he/she had any dental examinations completed. The program specialist reported to licensing staff on 11/21/16 that there was no way to determine if dental examinations were completed or if they were completed in a timely manner. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | This individual was seen by the dentist in April 13, 2016. The record of this appt is in the resident's daily notes. We did not have a form to demonstrate the visit. We have developed a form as referenced in previous violation summary 6400.163 (c), see attachment #37 The Dental Addendum. This individual will be seen by the dentist on April 5th, 2017 at 1:10pm. |
01/06/2017
| Implemented |
| 6400.145(3) | The written emergency medical plan did not include an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | WHO: The program specialist and director of human resources updated the policy on the emergency medical plan, attachment #1.
What: The emergency medical plan was revised to include the link between the supervisor and the team leader. The team leader is now directed to call the supervisor on call in the event of a medical emergency
When and How: All staff were retrained on the revisions of the policy, see Attachment #2. Moving forward the emergency medical plan with new provision will be addressed in new employee orientation and part of our annual mandatory in-service training.
Dates: 1/3/2017 |
01/06/2017
| Implemented |
| 6400.163(c) | Individual #1 had his/her psychiatric medications reviewed with a licensed physician on 3/8/16 and not again until 9/6/16, outside of the 3 month time frame. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Program Specialist had documentation in the chart for the two dates as listed above but the documentation was missing for a visit in June. Copies of the new scripts were in the chart, but our chart lacked the proper documentation of visits. The Program Specialist has reorganized the chart to separate the chart into a more user-friendly version as suggested in the survey. The new index for the charts is attachment #34. A new form was developed, " The psychiatry addendum" Attachment #35, it includes the psychotropic medication and provides space for the physician to document need to continue the medication. This form was put into place and utilized specifically with this individual on 12/27/16. Additionally, an appointment log was created and is located in the chart, the log includes the date, specialty and return date for quick and easy reference, see attachment #36. The staff was trained on the use of the new form for specialty appt's , see attachment #37. |
01/06/2017
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment completed on 1/27/16 did not indicate his/her level of need for supervision at home or in the community. The assessment only indicated he/she required supervision when getting ready for the day. | The assessment must include the following information: The individual's need for supervision.
| The Program Specialist re-wrote the Annual Assessment paying particular attention to the supervision assessment. This was completed on December 28th, attachment #33. In the future Program Specialist will write a more detailed supervision plan for individuals. |
01/06/2017
| Implemented |
| 6400.181(e)(12) | Individual #1's 1/27/16 assessment did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist completed the Annual Assessment, see attachment #33 paying particular attention to the areas of training, programming and services. The Assessment was much more detailed and individual specific. The recommendations section references changes necessary to the service plan for this individual. In the future the Program Specialist will continue to provide much more detail in the Assessment. |
01/06/2017
| Implemented |
| 6400.183(4) | Individual #1's Individual Support Plan (ISP) did not include a protocol and schedule outlining specific periods of time he/she can be without direct supervision. His/Her ISP only indicated "no significant supervision needs when in the community but does need supervision while in unfamiliar surroundings in the community. Home supervision requires supervision with managing personal hygiene, medications, diet, finances" but does not specify time periods for the supervision needs. | The ISP, including annual updates and revisions under § 6400.186 (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. | The Program Specialist re-wrote the supervision plan, which is attachment #32. The track changes were sent to the SC, changes have not been made officially yet. See the email to SC as presented as part of #32. The revised supervision plan is much more detailed to include specific individualized needs. In the future the Program Specialist will request utilize the input of by the other team members to adapt and change the supervision plan. |
01/06/2017
| Implemented |
| 6400.186(a) | The Individual Support Plan (ISP) reviews for Individual #1 were not completed every 3 months. He/She had ISP reviews completed on 1/19/16, 5/20/16, and 9/2/16. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Program Specialist created a new schedule for ISP quarterlies based on annual review date. The plan was emailed to the surveyor for approval, see attachment #26 on November 28th. The new schedule of quarterlies reviews was implemented immediately after receiving confirmation on the appropriateness of the schedule. Attachment #28 is this individual's quarterly summary for the quarter Sept. 2nd to Dec 2nd.
The next summary is also attached as #30, to demonstrate our understanding of the process. |
01/06/2017
| Implemented |
| 6400.186(d) | The Individual Support Plan (ISP) reviews for Individual #1 completed on 9/2/16, 5/20/16, and 1/19/16 were not sent to all team members. The ISP reviews were only sent to his/her supports coordinator. However Individual #1's team members consisted of a day program, job coaching agency, supports coordinator, and a sister. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The Program Specialist included on Attachment #28 evidence that all members of the support team were provided with a copy of the quarterly summary. Emailed to Supports Coordinator and day program provider, mailed to the sister and job coach. The CEO and Program Specialist reviewed the regulation and policy to ensure our compliance with the standard. Attachment 28a is a portion of the "Program" policy that reviews the requirements for quarterly reviews, 5(d) as highlighted instructs on the process for providing documentation back to team members within 30 days. |
01/06/2017
| Implemented |
| 6400.186(e) | The program specialist did not notify all of Individual #1's team members of the option to decline the Individual Support Plan (ISP) review documentation. His/Her team members consisted of a day program, job coaching agency, supports coordinator, and a sister. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Program Specialist provided the Option to Decline document to the Day-programer, attachment 28 on Dec 2nd. Previously all other team members were notified on August 25th, see attachment 27.
In the future, the Program Specialist will present the option to decline at the new/ or change of program meeting. |
01/06/2017
| Implemented |
| 6400.213(11) | The identification sheet in Individual #1's record indicated that he/she was currently living in Room #2 at 500 Front Street, Milesburg, PA. He/She currently resides at 512 Front Street, Milesburg, PA. Individual #1's assessment indicated he/she keeps a weekly amonetary llowance at the home that is logged and counted at the home. His/Her Individual Support Plan (ISP) indicated that he/she is able to handle some of his own money indiependently but does not specify the amount he/she was able to handle. The program specialist indicated on 12/21/16 that Individual #1 is completely independent with all of his finances and does not need to keep a log at the residence anymore. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The software program developer modified the form at the request of the program specialist to include the current address of the individual. This change in the form is attachment #25. Attachment #23 shows where we made the request for the change an attachment #24 the original face sheet where it does show there is the program address and not the specific address of the individual. The form has been modified for all individuals in the program. |
01/06/2017
| Implemented |