| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(3) | Individual #2's physical examination dated 5/9/22 and Individual #3's physical examination dated 7/20/22 did not include their immunizations as this section of their exams were left blank. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Reaching Beyond Limits will now utilize a cover sheet that will accompany all physical forms. This will have specific instructions on how to properly complete the form as well as a request for no blanks. Program Specialists will now follow a procedure in regards to physical forms. The procedure is as follows: Physical with cover letter will be sent out 45 days prior to expiration by the Program Specialist. The Program Specialists will monitor completion and send reminders as needs. Once the Physical is returned, the Program Specialist will review the document to ensure it is complete. Program Specialists must have Director of Day Program or the Assistant of Day Program review and stamp the physical prior to filing it in the Client¿s Binder. If the physical is not completed within 15 days of the expiration date, the client will not be able to attend program until it is received. If the physical is returned but not complete, the Program Specialist will send the physical and cover sheet back to be completed. |
08/18/2022
| Implemented |
| 2380.111(c)(7) | Individual #2's physical examination dated 5/9/22 and Individual #3's physical examination dated 7/20/22 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work as this section of their exams were left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Reaching Beyond Limits will now utilize a cover sheet that will accompany all physical forms. This will have specific instructions on how to properly complete the form as well as a request for no blanks. Program Specialists will now follow a procedure in regards to physical forms. The procedure is as follows: Physical with cover letter will be sent out 45 days prior to expiration by the Program Specialist. The Program Specialists will monitor completion and send reminders as needs. Once the Physical is returned, the Program Specialist will review the document to ensure it is complete. Program Specialists must have Director of Day Program or the Assistant of Day Program review and stamp the physical prior to filing it in the Client¿s Binder. If the physical is not completed within 15 days of the expiration date, the client will not be able to attend program until it is received. If the physical is returned but not complete, the Program Specialist will send the physical and cover sheet back to be completed. |
08/18/2022
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination dated 9/3/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency this section was left blank on the form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Reaching Beyond Limits will now utilize a cover sheet that will accompany all physical forms. This will have specific instructions on how to properly complete the form as well as a request for no blanks. Program Specialists will now follow a procedure in regards to physical forms. The procedure is as follows: Physical with cover letter will be sent out 45 days prior to expiration by the Program Specialist. The Program Specialists will monitor completion and send reminders as needs. Once the Physical is returned, the Program Specialist will review the document to ensure it is complete. Program Specialists must have Director of Day Program or the Assistant of Day Program review and stamp the physical prior to filing it in the Client¿s Binder. If the physical is not completed within 15 days of the expiration date, the client will not be able to attend program until it is received. If the physical is returned but not complete, the Program Specialist will send the physical and cover sheet back to be completed. |
08/18/2022
| Implemented |
| 2380.113(a) | Staff persons shall have a physical examination within 12 months prior to employment. Staff #3's date of hire is 1/24/22 and their physical examination is dated 1/26/22. This exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Reaching Beyond Limits will now utilize a new checklist for our onboarding process. This will clearly identify what items are needed PRIOR to the employee¿s first day of work. The Director of Human Services will monitor this process. |
08/18/2022
| Implemented |
| 2380.113(c)(3) | Staff #3's physical examination dated 1/26/22 did not included a signed statement that the person is free of serious communicable diseases. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | Reaching Beyond Limits will now utilize a cover sheet that will accompany all physical forms. This will have specific instructions on how to properly complete the form as well as a request for no blanks. The Director of Human Resources will review the document to ensure it is complete and stamp the physical prior to filing it in the employee¿s binder. If the physical is returned but not complete, the Director of Human Resource will send the physical and cover sheet back to be completed. |
08/18/2022
| Implemented |
| 2380.39(c)(1) | Staff #1 and Staff #2 did not receive annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Reaching Beyond Limits annual training curriculum has been updated to include the following:
- The application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.
- The prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101¿10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301¿6386), the Adult Protective Services Act (35 P.S. § § 10210.101¿10210.704) and applicable protective services regulations.
- Individual rights.
- Recognizing and reporting incidents.
- The safe and appropriate use of behavior supports if the person works directly with an individual.
- Implementation of the individual plan if the person works directly with an individual. |
08/18/2022
| Implemented |
| 2380.126(a)(5) | Individual #1's Medication Administration Record (MAR) did not include the strength of their medication Lorazepam. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The Medication Administration Record (MAR) that Reaching Beyond Limits utilizes has been updated to include a line for the strength of their medication administered. |
08/18/2022
| Implemented |
| 2380.166(4) | Individual #1's is prescribed has a medication Lorazepam for anxiety, take 1 tablet by mouth twice a day as needed for anxiety. The instructions for administration do not contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication. | The following procedures are prohibited: A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: (i) Treatment of the symptoms of a specific mental, emotional or behavioral condition. (ii) Pretreatment prior to a medical or dental examination or treatment. (iii) An ongoing program of medication. (iv) A specific, time-limited stressful event or situation to assist the individual to control the individual's own behavior. | When giving a PRN, Reaching Beyond Limits will now require a medical professional to provide instructions for administration that contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication.
The Director of Day Program is currently making efforts of obtain instructions for administration that contain the symptoms of the mental, emotional, or behavioral conditions that would indicate there is a need for the staff to administer the medication for the client that was referred to in the POC. RBL will not administer this medication until this is received. |
08/18/2022
| Implemented |