| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #1's was hired on 8/21/14, and the criminal history check was completed on 8/28/14. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The Assistant Executive Director will review all potential new hire applicant's paperwork and make sure that all applications for a Pennsylvania criminical history record check is submitted to the State Police before they are officially hired. |
02/13/2015
| Implemented |
| 6400.31(b) | Individual #1's signed rights were last completed on 1/13/12. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The Service Director will be responsible for making sure that all individual signed rights are completed, signed and dated annually. The Service Director or designee will audit all individuals records to ensure that the rights have been signed for 2014 and annual thereafter. The Service Director or designee will develop a tracking tool to ensure that all rights are signed on an annual basis, starting within 30 days of receipt of this plan of correction. [SW 2.12.15] |
02/13/2015
| Implemented |
| 6400.112(c) | The fire drill completed on 9/29/14 did not document the exit route. | 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 or smoke detector was operative. | The person conducting the fire drill will be retrained on how to complete the fire drill forms and will be double checked by the administrative assistant or designee to make sure the form is filled out correctly before the form is submitted and filed. The Program Director will conduct periodic checks of the fire drill records to ensure all required elements are noted on the form. |
02/13/2015
| Implemented |
| 6400.112(d) | The fire drill completed on 9/29/14 took 2 minutes and 40 seconds, which exceeded 2 ½ minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Management will speak to the Fire Marshal about extending the time for the fire drills. A second drill was held and it was completed within the 2.5 minute frame. We have one individual that refuses to leave the building sometimes because she states, "this is not a real fire, I an not going outside." The Director or designee will conduct a fire safety training with both staff and residents within 30 days of receipt of this plan of correction. In addition, when fire drill evacuations exceed 2.5 minutes, the home will conduct a second unannounced drill within the same month to ensure that all individuals evacuate. The individual that continues to refuse to participate bedroom should be located closest to the door to ensure that they can evacuate timely and to meet with the individual plus their supports coordinator to explain the importance of evacuating during a drill. |
02/13/2015
| Implemented |
| 6400.141(a) | Individual #1's current physical dated 9/30/14, and previous physical was completed on 9/4/13. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Nursing Supervisor will make monthly reviews of each individual's med book and make sure all doctor's appointments are scheduled and completed at the appropriate times. The nursing supervisor will conduct an audit of all participants annual physicals to ensure that they are completed timely. In addition, a tracking tool will be developed by the nursing supervisor to ensure that all physical examinations are conducted timely. |
02/13/2015
| Implemented |
| 6400.141(c)(7) | Individual #2's gynecological exam on 1/28/14 did not include a pap, which was last completed on 1/10/12. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The individual refused the Pap test. Nursing Supervisor will make sure that when an individual refuses an examination the doctor writes documentation that it is alright for the individual to have less frequent gynecological examinations. The nursing supervisor will develop a refusal plan for Individual #2 and recommendations on how to encourage the individual to participate in the pap examination. |
02/13/2015
| Implemented |
| 6400.181(f) | Individual #2's assessment dated 7/2/14 was not sent to the supports coordinator 30 days prior to the meeting on 8/22/14. | (f) The program specialist shall provide the assessment to the SC, 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 office staff will mail or staff will hand the assessment to the supports coordinator with a receipt form that will be signed by the supports coordinator. If the assessment is emailed, a copy of the email will be used as receipt. The Program Specialist will receive training on the importance of submitting the assessment 30 days prior to the ISP meeting. |
02/13/2015
| Implemented |