| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | There is no date as to when the fire notification letter was sent to the fire department. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A letter has been sent to the fire department. The letter now includes the date it was sent. The letter also includes a current residential setting. It describes the individuals living in the home and the location of their bedrooms. Kasey Bradley will be responsible to send the letter yearly or if a change in the home occurs. Compliance specialist will ensure that the letters are accurate and dated during his quarterly record reviews. completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.145(2) | The method of transportation to be used on the emergecny medical plan was not included. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | The method of transportation has been updated in the Emergency plan. The acronym ¿AMED¿ has been replaced by the term ambulance. AMED is a local ambulance company and using it as an identifier was not clear for ambulance. Quarterly record reviewed will be performed by compliance specialist, Andrew Hamilton. During this review he will ensure that the method of transportation is clearly documented in the Emergency Plan. Compliance Specialist will ensure that all medical emergency plans list the method of transportation to be used. He will monitor this during his quarterly record review. 6/30/17 |
06/30/2017
| Implemented |
| 6400.163(c) | Individual #1's psychiatric reviews dated 11/7/16 did not inlcude the reason each medication is prescribed and if the medication listed was to continue. | 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. | Health Coordinator will be retrained on job duties. This training will be done by director, Kasey Bradley. This training will include the need for a reason for each medication and if a need to continue is required. The health care coordinator will be responsible to have the prescribing physician list the reason for the medication and the need for it to continue. Compliance specialist will do quarterly record reviews. During these reviews any medications with out a reason and need for continue will be identified and the health care coordinator will be notified to make changes. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.164(a) | Repeat 1/4/17: Individual #1's medication logs did not contain individual names. It did not contain specific dates such as Januaray 2017. The medication logs were missing for Novmenber 2016 and December 2016. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | All current employees will be retrained on the PA DPW Medication Administration. Any newly hired staff will be trained on the PA DPW medication Administration. Beth Zeth or Amanda Barnhart will be responsible to schedule the trainings and ensure they are completed properly. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. Health Coordinator will be responsible to keep a copy of the MAR on file in her office. Compliance Specialist will conduct quarterly record reviews, during these reviews he will identify any errors and notify health coordinator. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.164(b) | Individual #1's mediction logs included the following errors. The zyprexa 20mg 1/2 tab 2 times at 4pm and 8pm. THe 3/14/17 8pm does was not signed for. The Prilosec DR 20mg 1 cap 1 times daily 8am. 3/9/17 was not signed. The Lactulose 10mg/15ml take 30ml 2 x daily for 30 days. The 8pm does on 1/19/17 was not signed for. The Depakote ER 500mg 3 tabs at 8pm. THe 8pm does on 1/19/17 and 1/23/17 was not signed for. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | All current employees will be retrained on the PA DPW Medication Administration. Any newly hired staff will be trained on the PA DPW medication Administration. Beth Zeth or Amanda Barnhart will be responsible to schedule the training's and ensure they are completed properly. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. Compliance Specialist will conduct quarterly record reviews, during these reviews he will identify any errors and notify health coordinator. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(b) | Individual #1's assessment dated 11/18/16 states 1:1 supervision but 2:1 supervision stated in December 2016. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | Program Specialists will be retrained on job duties. This training will be done by director Kasey Bradley. This training will review the need for an assessment for any recommendations to revise a service or outcome in the ISP. Program Specialists will be responsible to complete an assessment when recommending any a revision to a service or an outcome in the ISP. During Quarterly reviews, Compliance specialist will ensure that the assessments are completed and properly reflect the ISP. Completion Date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(f) | Individual #1's assessment dated 11/18/16 was not sent 30 days before the ISP meeting dated on 12/14/16. | (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).
| An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for the assessment to be sent to all team members 30 days prior to the ISP. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.183(4) | Individual #1's ISP states 1:1 supervision needed but 2:1 supervision has been provided to health and safety concern. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | A team meeting was held on 5/19/17. Individuals supports coordinator was asked to make the necessary changes ti the ISP to reflect the supervision. Support coordinator will make the changes as soon as the 2:1 staffing is approved. The support coordinator as well as the program specialists have updated the ISP and the assessment to reflect the need for 2;1 supervision. Compliance specialist will be responsible to ensure all supervision needs are reflected properly in each individuals ISP. During quarterly record reviews, if an error relating to supervision is found Compliance Specialist will notify Program specialist to make necessary changes. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.184(b) | Individual #1's ISP meeting did have the individual signature on the signature sheet. | At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting. | All current Program Specialists will be retrained on their job duties and sign the training. Kasey Bradley will be responsible for ensuring that all Program specialists are retrained. All new staff will be given their job description and trained on it. Jamie Zaliznock, HR director will be responsible to provide the training during orientation. (attachment #3)Program Specialist was trained on the importance of the individual attending the ISP. Program Specialist will be responsible to ensure that the individual signs the ISP attendance sheet. Kasey Bradley will provide the training to all current and newly hired Program Specialists. (attachment #6) Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that all individuals sign the ISP attendance sheet. Completion Date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.186(c)(1) | Individual #1's ISP monthly reviews were not completed for November 2016 to current. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | Program Specialists will be retrained on job duties. This training will be done by director, Kasey Bradley. This training will include the need for monthly reports and the proper method of completing them. Program specialist will be responsible to complete a monthly review on each individuals. The monthly report will be placed in the individuals record. during quarterly record reviews, compliance specialist will ensure that all monthly reviews are completed and in the individuals record. If the monthly reviews are not completed the compliance specialist will notify program specialist that they need completed. COmpletion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.186(c)(2) | Individual #1's ISP review dated 1/27/17 had an outcome to learn his medication and take care of shaving were not reviewed. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Program Specialists will be retrained on job duties. This training will be done by director, Kasey Bradley. This training will include the need for monthly reports and the proper method of completing them. Program specialist will be responsible to complete a monthly review on each individuals. These reviews will include a review of each section of the ISP specific to the residential home. The monthly report will be placed in the individuals record. during quarterly record reviews, compliance specialist will ensure that all monthly reviews are completed and in the individuals record. If the monthly reviews are not completed the compliance specialist will notify program specialist that they need completed. Completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.186(e) | Individual #1's ISP reviews did not include the option to decline. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | A new declination form for the ISP review has been developed. All individuals team members will be asked to fill out the declination form at each ISP review. Program specialist will be required to provide the declination form to the team members. Compliance specialist will ensure all team members have indicated whether they would like to receive the Quarterly review during his record review. completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.195(b) | Individual #1's restrictive plan did not include the program specialist and direct care staff when developing the plan. | The restrictive procedure plan shall be developed and revised with the participation of the program specialist, the individual's direct care staff, the interdisciplinary team as appropriate and other professionals as appropriate.
| All current Program Specialists will be retrained on their job duties and sign the training. Kasey Bradley will be responsible for ensuring that all Program specialists are retrained. All new staff will be given their job description and trained on it. Jamie Zaliznock, HR director will be responsible to provide the training during orientation. (attachment #3) these duties will include attending the Human Rights Committee meetings in order to participate in the implementation of the Restrictive Procedure Plan (Attachment #4). Compliance Specialist will ensure that the staff and program specialist help develop the restrictive procedure plan during his quarterly record reviews. completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.195(c) | Individual #1's restictive plan dated 11/1/16 but was not updated to include the 2:1 supervision that started on Novemeber 2016. | The restrictive procedure plan shall be reviewed, and revised, if necessary, according to the time frame established by the restrictive procedure review committee, not to exceed 6 months.
| A team meeting was held on 5/19/17. Behavior Support was asked to make the necessary changes ti the BSP to reflect the supervision. . The support coordinator as well as the program specialists and behavior support have updated the BSP and the assessment to reflect the need for 2;1 supervision. Compliance specialist will be responsible to ensure all supervision needs are reflected properly in each individuals ISP. During quarterly record reviews, if an error relating to supervision is found Compliance Specialist will notify Program specialist to make necessary changes. Completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.195(d) | Individual #1's restrictive plan was not signed or dated by the program specialist prior to the use of the plan. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| All current Program Specialists will be retrained on their job duties and sign the training. Kasey Bradley will be responsible for ensuring that all Program specialists are retrained. All new staff will be given their job description and trained on it. Jamie Zaliznock, HR director will be responsible to provide the training during orientation. (attachment #3) these duties will include attending the Human Rights Committee meetings in order to participate in the implementation of the Restrictive Procedure Plan (Attachment #4)Compliance Specialist will ensure that the staff and program specialist help develop and sign the restrictive procedure plan during his quarterly record reviews. completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not contain religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Program Specialist will be retrained on job duties. This training will be done by Director, Kasey Bradley. This training will include the need for personal information including religious affiliation to be included int eh individuals permanent record by the program specialist. The compliance specialist will do a record review quarterly. During the reviews, the compliance specialist will ensure that religious affiliation is added to the permanent record. If it is left absent, he will notify program specialist to update the record.. Completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.213(11) | Individual #1's record had the following discrepancies: ISP dated 3/21/17 contained his previous address of 442 Old Route 22, Duncansville which is a hotel and moved in Januarary 2017. The ISP states Topamax 100 mg - Bipolar D/O. The medication log states Topamax 10mg for seizure D/O. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | A training on content discrepancies has been developed. (Attachment#2) All current and new program Specialists will be trained. Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. Any other team members, employed by Crossroads Services Inc., who contribute to the development of the ISP, Assessment, or other documentation will also be required to have this training. Compliance specialist will ensure that content discrepancies are fixed during his quarterly record review. completion date 6/30/17 |
06/30/2017
| Implemented |