| 6400.32(r) | Individual Rights for individual #2 were missing statements regarding locks. | An individual has the right to lock the individual's bedroom door. | 1. A plan to fix the immediate problem:
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future.
The CCS CEO and the CCS Director.
b. WHAT will be corrected
The Individual Rights Packet is missing the statement that individual has the right to lock the individual's bedroom door.
c. WHEN the correction will be completed?
The Rights packed was revised on 12/23/2024. It was reviewed with all individuals on 12/30/24 and signatures were obtained. (see attachment #5)
d. HOW (usually attached as procedure)
The CEO took the Individual Rights section or the 6400 regulations and ensured that all items listed on the regulations were included. (See attachment #3)
2. The POC must address the exact violation(s) that were cited in the LIS.
The exact violation was 55 PA Code Chapter 6400.32(r)
3. Since ODP measures compliance based on samples, providers must indicate a review of all resident or staff records to determine if any others are out of compliance and need to be corrected.
All records were updated and reviewed with the individual and their team.
4. Target dates for completion of each step.
The Rights packet was revised on 12/23/2024 and was reviewed and presented to all individuals served though CCS for signatures. All packets were signed and filed in individual files by 12/30/2024.
5. Specific dates by which correction tasks will be completed are required to effectively monitor plan completion.
The Rights packet was revised on 12/23/2024 and was reviewed and presented to all individuals served though CCS for signatures. All packets were signed and filed in individual files by 12/30/2024. |
12/30/2024
| Implemented |
| 6400.34(a) | Individual Rights for individual #2 signed on 11/25/2024 instead of admission date of 11/1/24. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | 1. A plan to fix the immediate problem:
a. WHO (job title) will be responsible for correcting the problem (each step of the process) in the future.
CCS has ensured that those admitted since this violation have had the rights packet signed prior to or upon admission on the admissions check list.
b. WHAT will be corrected
CCS will correct the violation that was a result of the individual rights packet being signed on 11/21/24 instead of 11/1/2024. The rights packet was presented to the family on the move-in date as the individuals father is the power of attorney. However, the POA did not sign the paperwork on the move-in date.
c. WHEN the correction will be completed.
This violation for this particular individual could not be corrected as time had already passed. However, going forward, CCS will present an admissions checklist to the families to be completed by move-in date. (See attached CCS move-in checklist Attachment #6) This checklist will be completed by the Program Specialist to ensure that all items that are required are completed on time. |
12/30/2024
| Implemented |