| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(1) | The program specialist did not complete Individual #1's assessments dated 8/3/15 and 1/10/16. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | A new annual assessment tool will be developed by 07/01/2016. Beginning 03/05/2016 only staff who meet the Program Specialist employment qualifications have been completing assessments. Program Managers will ensure assessments are completed in full and signed by staff who meet the Program Specialist employment qualifications. Individual #1 of 2818 Florence will have a new assessment completed by 07/15/2016. [Immediately, all program specialists will be informed of their responsibilities including coordinating and completing assessments by CEO or designated supervisory staff person. At least quarterly for 1 year, CEO or designated management staff will review a 10% sample of completed assessment to ensure program specialist are completing assessments for all individuals as required. Documentation of reviews shall be maintained. (AS 5/25/16)] |
05/02/2016
| Implemented |
| 6400.112(c) | The fire drill records for the fire drill held on 6/7/15, 7/8/15, 9/2/15, and 12/21/15 did not indicate if a smoke detector or fire alarm was operative. | 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. | Program Managers and House Supervisors in Erie were retrained by Program Director on 04/04/2016 on completing fire drill forms and reviewing fire drill forms for completeness. The Compliance Officer will reveiw March and April 2016 fire drill records from individual #1 home at 2818 Florence to verify proper procedures were followed and the forms were fully completed. A process to check fire drill records to ensure all necessary sections are complete will be developed by Program Directors by 06/01/2016. [Within 90 days of receipt of the plan of correction, all staff responsible for conducting and documenting fire drills will be trained by the program director or designated supervisory staff person to ensure fire drills are conducted and documented as required. At least quarterly for 1 year the compliance officer or designated supervisory staff person will review all fire drill records to ensure fire drill are conducted and documented as required. Documentation of reviews shall be kept. (AS 5/25/26)] |
05/02/2016
| Implemented |
| 6400.141(c)(7) | Individual #1, admitted 6/20/1988 had a gynecological examination on 4/17/15, there was not documentation of a prior gynecological examination; therefore compliance could not be measured. Individual #1's date of birth is 11/28/1962. | 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. | A complete review of medical records will be done by 05/15/2016 to determine why there was no documentation of prior gynecological exam for Individual #1. A copy of Individual #1 previous gynecological exam records will be obtained from Individual #1 physicians. A written process for medical follow/up, annual appointments, completion of forms and compliance with required dates will be established by 06/01/2016. Staff will be given the written process. Program Directors will ensure the process is being followed. [Individual #1 had a gynecological examination on 4/18/16. Immediately, CEO and/or designated management staff person will develop, implement and train all involved staff persons in a tracking system to ensure all individuals have physical examinations within required timeframes. At least quarterly, the tracking system and a 10% sample of all individual physical examinations will be reviewed by designated management staff to ensure all individuals' physical examinations are completed within the required timeframes. Documentation of trainings and reviews shall be kept. (AS 5/25/16)] |
05/02/2016
| Implemented |
| 6400.141(c)(8) | The mammogram for Individual # 1, date of birth 11/28/1962, was completed on 4/11/14 and 5/1/15. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | A complete review of medical records will be done by 05/15/2016 to determine why Individual #1 mammogram was 20 days late. A mammogram was completed on 04/11/2014 and 05/01/2015. The Program Manager will verify a mammogram was done within one year of the last one dated 05/01/2016. A written process for medical follow-up, annual appointments, completion of forms and compliance with required dates will be established by 06/01/2016. Staff will be given the written process. Program Directors will ensure Individual #1 receives a mammogram for women at least every year for per regulation 6400.141 (c)(8). [Immediately, CEO and/or designated management staff person will develop, implement and train all involved staff persons in a tracking system to ensure all individuals have physical examinations within required timeframes. At least quarterly, the tracking system and a 10% sample of all individual physical examinations will be reviewed by designated management staff to ensure all individuals' physical examinations are completed within the required timeframes. Documentation of trainings and reviews shall be kept. (AS 5/25/16)] |
05/02/2016
| Implemented |
| 6400.163(c) | Individual #1 is prescribed Citalopram 10mg for depression. The psychiatric medication reviews for Individual #1 were completed on 9/14/15 and then again on 1/14/16. | 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. | Will review Individual #1 psychiatric records to deteremine why psych med review was 30 days late. A written process for medical follow/up, annual appointments, completion of forms and compliance with required dates will be established by 06/01/2016. Staff will be given the written process. Program Directors will ensure the process is being followed. [Immediately, CEO and/or designated management staff person will develop, implement and train all involved staff persons in a tracking system to ensure all individuals have psychiatric medication reviews within required timeframes. At least quarterly, the tracking system and a 10% sample of all individual psychiatric medication reviews will be reviewed by designated management staff to ensure all individuals' psychiatric medication reviews are completed within the required timeframes. Documentation of trainings and reviews shall be kept. (AS 5/25/16)] |
05/02/2016
| Implemented |
| 6400.181(f) | The assessments for Individual # 1, dated 8/3/15 and 1/10/16, were not sent to the entire team including the adult training facility and the community habilitation provider. | (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).
| Individual's #1 assessment will be sent to the entire team including the ATF and Community Habilitation Provider by 05/15/2016. Program Managers and House Supervisors in Erie were retrained by Program Director on 04/04/2016 on providing 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). A written process will be developed by Program Directors to ensure assessments are shared with the entire team by 06/30/2016. All staff will be given this written process to follow. Program Managers will ensure House Supervisors are providing assessments to the team on time per regulations. [Individual #1's assessment was sent to the all plan team members on 4/12/16 as required. Prior to sending assessments within the required time frames, program specialists will review all individuals' invitation letters, ISPs and other documentation in the individuals' records to ensure the entire team is provided the assessments for all individual and correspondence documentation is maintained. At least quarterly, CEO or designated management staff person will review a 10% sample of correspondence to ensure all team members are provided individuals' assessments as required. Documentation of reviews shall be maintained. (AS 5/25/16)] |
05/02/2016
| Implemented |