| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(d) | Staff 1 has a date of hire of 8/13/2015. Staff 1 had a criminal history requested on 8/7/2015 that states that it is Under Review. The agency did not obtain additional information from the PA state Police as to why staff 1's record is under review. Criminal History Record Checks are not final if the record is Under Review. | A copy of the final reports received from the State Police, and the FBI, if applicable, shall be kept. | Final Criminal History Record Check indicating no criminal record was received by HR on 8/17/15 but was not in Staff 1's file. A copy of the results will be emailed to licensing representative. (Attachment 6). |
03/10/2016
| Implemented |
| 2380.111(c)(4) | Individual 2's physical dated 7/9/2015 did not include a vision screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | A checklist was developed to track physicals and ensure that all sections are completed. Individual 2's physical was returned to her physician to have all necessary areas completed. (Attachments 5A-5D) |
04/18/2016
| Implemented |
| 2380.111(c)(8) | Individual 1's physical dated 5/14/15 was blank in the physical limitations section. | The physical examination shall include: Physical limitations of the individual. | Individual 1's physical was returned to his physician with a letter requesting what information must be completed. We are currently awaiting a FAX from the doctor. A checklist was developed to track physicals and ensure that all sections are completed. (Attachments 5A & 5B) |
04/29/2016
| Implemented |
| 2380.124(b) | Individual 3 was administered the following 2 medications on 3/8/2016 but they were not logged on individual 3's medication log: Misoprostol 200 mcg., 1 tablet by mouth 4 times a day; and Lamotrigine 200 mg take 1 tablet by mouth 3 times daily. On the back of both blister packs was "LY on 3/8/16 @11:25am" to indicate that the pills were given by staff person 2. | The information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication. | Staff person responsible received remediation training on 3/11/16 and 3/14/16. (Attachment 4A & 4B). |
03/14/2016
| Implemented |
| 2380.173(1)(ii) | Individual 1's record did not include his height, hair color, or eye color. Individual 4's record did not provide information on identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | As of April 2016, all new admissions will have a formal admission meetings held with the team prior to their start date to ensure that all paperwork is filled out completely. Completed forms for individuals 1 and 4 will be emailed to licensing representative. (Attachments 2A & 2B) |
04/01/2016
| Implemented |
| 2380.173(1)(iv) | Individuals 1 and 4 record does not include his religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | As of April 2016, all new admissions will have a formal admission meetings held with the team prior to their start date to ensure that all paperwork is filled out completely. Completed forms for individuals 1 and 4 will be emailed to licensing representative. (Attachments 2A & 2B) |
04/01/2016
| Implemented |
| 2380.188(b) | Community opportunities are not being provided to all of the individuals in the program. Individual 1 has not been provided community outings since his date of admission on 10/14/2015 (5 months). Individual 2 has not been provided community outings since her date of admission on 7/21/15 (8 months). Individual 5 has not been provided community outings by the agency since 9/8/2014. | The facility shall provide opportunities and support to the individual for participation in community life, including work opportunities. | Individual 1 attends day program three days per week. He was on an outing to Berkshire Mall on 1/7/16 which is documented in progress notes. Program Specialist/Site Supervisor is now scheduling rotating outings weekly for all individuals who attend program. Individual 1 was also on an outing to Cabela's and Hamburg Park on 3/31/16 and is scheduled for another outing on 4/22/16. Outings are tracked on a monthly calendar, weekly and monthly progress notes, and quarterly reviews. Documentation will be emailed to licensing representative. (Attachments 1A & 1B) |
04/21/2016
| Implemented |