| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(i) | Staff #5 was not trained in first aide within 6 months of initial employment. Date of initial employment was 10/6/2014. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The Director of Training and Compliance is responsible for correcting the immediate problem. In order to correct the immediate problem:
1. Director of Training and Compliance ensured that staff person #5 was not left alone with any individuals during the time compliance did not occur.
2. Staff person #5 obtained the necessary training on 5/12/2015. (6th Avenue Attachment #5).
Upon discovery of violation of 55 PA Code Chapter 6400.46(i) in addition to the plan to correct the immediate problem, all staff¿s First Aid/CPR Dates were reviewed to determine compliance with this chapter. In July 2014 a tracking system was developed to track staffs First Aid/CPR dates and is attached for review, and to show ongoing compliance (6th Avenue Attachment #6).
|
06/30/2015
| Implemented |
| 6400.163(c) | Individual #1's pyschiatric medication reviews were not completed quarterly. 11/20/2014 and 3/19/2015. On 3/19/2015 check didnt review her Lamotrigne. 11/20/2014 check didnt include her Psychiatirc medications and no reason for prescribing. 8/20/2014 check had no dosages noted and states disgnosis of OCD and impluse control , bipolar which are not individual #1's diagnosis. | 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 Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The Psychiatric Medication Reviews were reviewed to determine if compliance was not present in any other areas.
2. All staff were retrained on medications, including Psychiatric medication reviews-what needs to occur, the requirements around 6400.163(c) specific to the requirements held by FSI. (6th Avenue Attachment #4)
Upon discovery of violation of 55 PA Code Chapter 6400.163 (c) 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 requirements of this chapter, including FSI policies and procedures around Psychiatric Medication Reviews. This training occurred on June 30, 2015. (6th Ave Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment did not include the ability to safely use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The Program Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment viewed at licensing was reviewed and did in fact include individual #1¿s ability to safely use/avoid poisonous materials. This assessment as attached for review with this information highlighted. (6th Avenue Attachment #1)
Upon discovery of violation of 55 PA Code Chapter 6400.181(6) no other actions were taken due to discovery of compliance.
To prevent future occurrence all Program Specialists were trained on completion of assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (6th Avenue Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(7) | Individual #1's assessment did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The Program Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on June 3, 2015 to include The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources. The assessment reviewed at licensing, as well as the updated assessment are attached for review. (6th Avenue Attachment #1 and #3)
Upon discovery of violation of 55 PA Code Chapter 6400.181(7)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 of assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (6th Avenue attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment did not include progress over the last 365 calendar days and current level in motor and communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Program Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on June 3, 2015 to include The individual's progress over the last 365 calendar days and current level in Motor and communication skills. The assessment reviewed at licensing, as well as the updated assessment are attached for review. (6th Avenue Attachment #1 and #3)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(ii)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 of assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (6th Avenue Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment did not 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 Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on June 3, 2015 to include the individual's progress over the last 365 calendar days and current level in Activities of residential living. The assessment reviewed at licensing, as well as the updated assessment are attached for review. (6th Avenue Attachment #1 and #3)
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 of assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (6th Avenue Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment did not 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 Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on June 3, 2015 to include the individual's progress over the last 365 calendar days and current level in socialization. The assessment reviewed at licensing, as well as the updated assessments are attached for review. (6th Avenue Attachment #1 and #3)
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 of assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (6th Avenue Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment did not include progress over the last 365 calendar days and current level in fincancial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment was updated on June 3, 2015 to include the individual's progress over the last 365 calendar days and current level in financial independence. The assessment reviewed at licensing, as well as the updated assessments are attached for review. (6th Avenue Attachment #1 and #3)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(vii)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 of assessments, and all information that must be included in Assessments. This training occurred on June 30, 2015. (6th Avenue Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment did not 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 Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment reviewed at licensing was reviewed by Program Director and determined that it did in fact include Progress and growth over the last 365 days in managing personal property. Specifically discussing individual #1¿s issues over the past year with messing her undergarments and putting them back in her drawer, as well as maintaining her ability to get things ready to take home on the weekends with her parents. Attached is the assessment for review (6th Avenue Attachment #1)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(viii) no other actions were taken due to discovery of compliance.
To prevent future occurrence all Program Specialists were trained on completion of assessments, and all information that must be included in Assessments as well as the need to be very clear as far as progress and growth are concerned. This training occurred on June 30, 2015. (6th Avenue Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment did not include progress over the last 365 calendar days and current level in community-integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The Program Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment reviewed at licensing was reviewed by the Program Director and it was determined that it did in fact include progress over the last 365 calendar days and current level in community integration. It specifically outlined the things she did in the last 365 days to continue and expand on her high involvement in the community. (6th Avenue Attachment #1)
Upon discovery of violation of 55 PA Code Chapter 6400.181(13)(ix) no other actions were taken due to discovery of compliance.
To prevent future occurrence all Program Specialists were trained on completion of assessments, and all information that must be included in Assessments as well as the need to be very clear as far as progress and growth are concerned. This training occurred on June 30, 2015. (6th Avenue Attachment #2)
|
06/30/2015
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment did not include progress over the last 365 calendar days and current level in knowledge of water safety and ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The Program Director is responsible for correcting the problem. In order to correct the immediate problem:
1. The assessment reviewed at licensing was reviewed by the Program Director and it was determined that it did in fact include progress over the last 365 calendar days and current level in knowledge of water safety and ability to swim. This section in the ISP was updated to include that her need for supervision remains the same. No progress or growth occurred in the year prior to. (6th Avenue Attachment #1)
Upon discovery of violation of 55 PA Code Chapter 6400.181(14) no other actions were taken due to discovery of compliance.
To prevent future occurrence all Program Specialists were trained on completion of assessments, and all information that must be included in Assessments as well as the need to be very clear as far as progress and growth are concerned. This training occurred on June 30, 2015. (6th Avenue attachment #2)
|
06/30/2015
| Implemented |