| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The kitchen refrigerator needs cleaned. Soiled food stains, little hairs, and sticky surfaces. | Clean and sanitary conditions shall be maintained in the home. | The Program Specialist/Program Staff are responsible for correcting the problem. In order to fix the immediate problem:
1. An email was sent from the Program Specialist on May 8, 2015 at 4:04pm instructing staff to clean out the refrigerator. Staff responded at 6:51pm confirming that the refrigerator had been cleaned (Brooks Mills Attachment #14). A photograph of the clean refrigerator is attached for review (Brooks Mills attachment #15) Staff cleaned it too quickly to get a before picture.
Immediately following licensing on site visit, upon discovery of violation of 55 PA Code Chapter 6400.64(a) in addition to the correction of the immediate problem, all Program Specialists were re-trained on June 30, 2015 on the importance of clean and sanitary conditions being maintained in the home, as well as their responsibility to conduct regular walk through of the home to ensure compliance in all physical site regulations. Training documentation is attached (Brooks Mills Attachment #3).
To prevent future occurrence all Program Specialists have been reminded of the importance of site walk through being conducted to ensure compliance in all areas of physical site regulations.
|
05/08/2015
| Implemented |
| 6400.74 | The small ramp off of the kitchen door leading to deck needs non skid strips replaced. They are almost gone. | Interior stairs and outside steps shall have a nonskid surface.
| The Program Specialist and Maintenance team are responsible for correcting the problem. In order to correct the immediate problem:
1. A maintenance request was sent on May 11, 2015 at 9:55am requesting that non-skid strips be added to the ramp off of the kitchen door.
2. On 6/2/2015 maintenance team corrected the problem, replacing the non-skid strips on the ramp (Brooks Mills attachment #13).
Upon discovery of non-compliance of violation PA 55 Code Chapter 6400.74 in regard to outside steps having nonskid surfaces, in addition to the immediate fix to the problem, all Program Specialists were retrained on the requirements of this chapter, including completion of regular on site walk through to determine compliance in all areas of the physical site (Brooks Mills Attachment #3).
To prevent future occurrence all Program Specialists have been reminded of the importance of site walk through being conducted to ensure compliance in all areas of physical site regulations.
|
06/02/2015
| Implemented |
| 6400.142(f) | Individual #1's record did not contain a dental hygiene plan and there is not one in place at the current time. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The Program Specialist is responsible for correcting the problem. In order to correct the immediate problem:
1. Individual #1¿s ISP was reviewed and it was determined that a dental plan was in fact in the plan, and progress toward that plan is noted on his daily logs. The Individual Support Plan that was reviewed at licensing is attached for review (Individul #1's Attachment #10) as well as the Daily Log that was reviewed at licensing (Individual #1's Attachment #11) and the updated daily log (Individual #1's Attachment #12).
Upon receipt of request of correction action, in response to violation of 55 PA Code Chapter 6400.142(f) in addition to the correction of the immediate problem, no other actions were taken due to discovery of compliance. |
06/30/2015
| Implemented |
| 6400.164(b) | Individual #1's 9/30/2014 dose of Topamae 2mg, Ensure plus, and Zyprexa 20mg was not initialed @ 8pm as given. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | The Program Specialist is responsible for correcting the problem. In order to fix the immediate problem:
1. The Medication Administration Record in question was reviewed on May 8, 2015 to determine exactly what medications were not signed for.
2. Daily documentation was reviewed and discussion with staff determined that the medication was in fact given, but not properly logged immediately after giving the dose of medication. The staff was instructed to document this information on June 25, 2015 upon receipt of the request for Corrective Action.
3. The MAR which was reviewed at licensing as well as the signed MAR are attached for review to show compliance (Individual #1's Attachment #8)
Upon receipt of request for corrective action, in response to violation of 55 PA Code Chapter 6400.164(b) in addition to the correction of the immediate problem, all staff were retrained in problem areas focusing around medication administration. This was held during the month of May 2015 for all staff employed by Family Services during that time. Attached is a summary of the training (Individual #1's Attachment #9)
To prevent future occurrence, on June 30, 2015 all Program Specialists were trained on the importance of documentation for Medication Administration. All Program Specialists were instructed that effective July 1, 2015 all MARs should be reviewed at least quarterly to determine if all medications are signed for. This should be done and documented by initialing the bottom of the Medication Administration Record. If any medication errors or errors in documentation are discovered the Program Specialist is responsible for taking appropriate action. Attached is a summary of the training held with Program Specialists on June 30, 2015 (Individual #1's Attachment #3). |
06/25/2015
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment did include progress over the last 365 calendar days and current level in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The Program Specialist is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on July 2, 2015 to include progress over the last 365 days and current level in activities of residential living. (Brooks Mills Attachment #4 & #5)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(iii) in addition to the correction of the immediate problem, All files for individuals falling under 6400 regulations were reviewed prior to May 30, 2015 to ensure compliance, and adjustments were made as needed.
To prevent future occurrence all Program Specialists were trained on completion off assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (Brooks Mills Attachment #3)
Attached for review is an assessment completed since on site licensing by Program Specialists that shows progress in the activities of residential living. (Brooks Mills Attachment #6 & #7)
|
07/02/2015
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's assessment did include progress over the last 365 calendar days and current level in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The Program Specialist is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on July 2, 2015 to include progress over the last 365 days and current level in personal adjustment (Brooks Mills Attachment #4 & #5)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(iv) in addition to the correction of the immediate problem, All files for individuals falling under 6400 regulations were reviewed prior to May 30, 2015 to ensure compliance, and adjustments were made as needed.
To prevent future occurrence all Program Specialists were trained on completion off assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (Brooks Mills Attachment #3)
Attached for review is an assessment completed since on site licensing by Program Specialists that shows progress in the personal adjustment for individual. (Brooks Mills Attachment #6 & 7)
|
07/02/2015
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment did include progress over the last 365 calendar days and current level in socialization. | 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. | The Program Specialist is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on July 2, 2015 to include progress over the last 365 days and current level in socialization. Attached is the assessment reviewed at on site licensing, as well as the revised assessment (Brooks Mills Attachment #4 & #5)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(v) in addition to the correction of the immediate problem, All files for individuals falling under 6400 regulations were reviewed prior to May 30, 2015 to ensure compliance, and adjustments were made as needed.
To prevent future occurrence all Program Specialists were trained on completion off assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (Brooks Mills Attachment #3)
Attached for review is a previous year, as well as an assessment completed since on site licensing by Program Specialists that shows progress in socialization (Brooks Mills Attachment #6 & 7)
|
07/02/2015
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment did include progress over the last 365 calendar days and current level in recreation. | 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. | The Program Specialist is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on July 2, 2015 to include progress over the last 365 days and current level in Recreation. Attached is the assessment reviewed at on site licensing, as well as the revised assessment (Brooks Mills Attachment #4 & #5)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(vi) in addition to the correction of the immediate problem, All files for individuals falling under 6400 regulations were reviewed prior to May 30, 2015 to ensure compliance, and adjustments were made as needed.
To prevent future occurrence all Program Specialists were trained on completion off assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (Brooks Mills Attachment #3)
Attached for review is a previous year, as well as an assessment completed since on site licensing by Program Specialists that shows progress in Recreation (Brooks Mills Attachment #6 & 7)
|
07/02/2015
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment did include progress over the last 365 calendar days and current level in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The Program Specialist is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on July 2, 2015 to include progress over the last 365 days and current level in Managing personal property. Attached is the assessment reviewed at on site licensing, as well as the revised assessment (Brooks Mills Attachment #4 & #5)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13) (viii)in addition to the correction of the immediate problem, All files for individuals falling under 6400 regulations were reviewed prior to May 30, 2015 to ensure compliance, and adjustments were made as needed.
To prevent future occurrence all Program Specialists were trained on completion off assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (Brooks Mills Attachment #3)
Attached for review is a previous year, as well as an assessment completed since on site licensing by Program Specialists that shows progress in Managing personal property (Brooks Mills Attachment #6 & 7)
|
07/02/2015
| Implemented |
| 6400.183(5) | Individual #1's ISP did not include a protocol to adress the SEEN PLAN. | The ISP, including annual updates and revisions under § 6400.186 (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. | The Program Specialist and Program Director are responsible for correcting the problem. In order to fix the immediate problem:
1. A Plan of Support addressing a protocol around Social, emotional and environmental needs of individual #1 was created and implemented/trained on with staff on 6/22/2015 Individual #1's Attachment #1)
2. Adjustments to the Individual Support Plan were implemented on 6/24/2015 (Individual #1's Attachment #2).
Upon discovery of violation around 55 PA Code Chapter 6400.183(5) in addition to the correction of the immediate problem, All Program Specialists were trained on the requirements of this chapter including the need for a SEEN plan to address the social, emotional and environmental needs of individual if a medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.
In order to prevent future occurrence all Program Specialists were trained on June 30, 2015 on the requirements of this chapter, including the requirements around SEEN plans. (Individual #1's Attachment #3)
To determine compliance across the agency, All Program Specialists were instructed to review all plans prior to July 15, 2015 and determine if SEEN plans are present for individuals served in 6400 that have a medication to treat symptoms of a diagnosed psychiatric illness. If a seen plan is not in place for any one individual, a plan will be put into effect no later than August 31, 2015. |
08/31/2015
| Implemented |