| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Multiple checks for hundreds of dollars per check, were written to home supervisor, Staff #2, to cash and deposit into Individual #1's financial record. However, on every occasion a check is written to staff, there are many days, and occasionally weeks, that pass before the cash funds are available to individual #1 in her home. Examples include: $300 check written on 8/14/2020 was not deposited into Individual #1's spending funds at the home until 9/3/2020 and $350 check written on 9/14/2020 was not deposited until 9/21/2020. There was no evidence provided by the agency to verify that as soon as the funds were cashed, they were deposited and available to Individual #1. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | All Supervisors and Program Specialists were retrained, as well as the rep payees, that checks will no longer be written out to the house supervisor, but they will be addressed to the individual, unless otherwise in the ISP. If the check cannot be picked up in a timely manner proper documentation will be made to as to why. This will allow the individual to be part of the banking process. The house supervisor will also make a copy of the check. The house supervisor will continue to complete weekly audits. The program Specialist will continue to contact all rep payees and ensure all checks written to the Individuals are accounted for when completing quarterly audits. If an individual refuse to go to the bank there will be documentation in the ISP, which will be updated by the Program Specialist. Audit forms that were completed through the year are attached to show that the accounts are monitored. The agency policy is to be adhered to at all times. Completed: 10/26/2020 |
10/26/2020
| Implemented |
| 6400.22(d)(2) | Individual#1's financial records are not kept up to date to include the exact date of purchase for items. For example: amazon purchase of $28.99 occurred on 8/20/2020 but deducted from her account on 8/25/2020, 8/7/2020 amazon purchase for $12.43 was not recorded on her financial record until 8/11/2020, 8/9/2020 dollar general purchase for $8.42 not recorded on her financial record until 8/11/2020, 7/28/2020 lakeside purchase for $9.53 not recorded on her financial record until 8/6/2020. Individual #1 8/7/2020 amazon receipt only listed that Individual #1 item purchased was $11.73 and staff #2 added $.70 tax for a total of $12.43. there is no evidence from the receipt that Individual #1's item purchased required taxed. The receipt also includes 5 other items purchased. 7/13/2020 Walmart receipt for $37.60 was not recorded on her financial record until 7/15/2020. | (2) Disbursements made to or for the individual.
| All Program Specialists and Supervisors were re-trained that they will no longer order items for the individuals on line. That if anyone would like to order on line, the individual will purchase a MasterCard/Visa gift card or teat specific stores gift card and a ledger for each card will be held and all receipts and invoices will be attached. All items will be delivered to their homes. Attached is a ledger ad receipts for amazon orders for the individual. Completed 10/26/2020 |
10/26/2020
| Implemented |
| 6400.22(e)(3) | The agency assumes responsibility of maintaining individual #1's finances by way of representative payee. All of the individual's bank account records, record debits from her account every month for large sums of money, but no record of where the money had gone, an itemized log of what was purchased, etc. Examples include: check #1500 was deducted from her account for $50.27 on 5/21/2020 and check#1501 was deducted from her account on 5/18/2020 for $15.62, check #1499 deducted on 6/1/2020 for $579.67, check#1493 deducted from her account on 5/1/2020 for $579.67. There is no evidence of where these funds went, an itemized receipt of what was purchased, etc. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | At the time of inspection the CPO was not aware that further documentation was acquired for checks that had been cashed and what they are for. The rep payee was at the office and not at the home at the time of inspection. The rep payee was able to provide all documentation. It is enclosed to ensure that there is no co-mingling of funds by the rep payee. This was completed: 10/30/2020 |
10/30/2020
| Implemented |
| 6400.22(f) | The home assumes responsibility of maintaining Individual #1's finances by way of representative payee. Staff person #3 is noted at the agency representative payee responsible for managing Individual#1's checking account. Multiple times throughout the year, hundreds of dollars is payed to the home supervisor, staff person #2, by way writing a check to the staff person.; 9/14/2020 $350, 8/14/2020 $300, 9/3/2020 $300, 7/10/2020 $300, 6/12/2020 $450, 3/31/2020 $500, 12/31/19 $250, etc. The checks listed they were for "Individual #1's spending money." Staff person #2 has cashed the check, obtaining ownership of the funds, prior to transferring said money back to the individual's account. Individual#1 and staff accounts and funds cannot be comingled. Per staff #4 there is no agency oversite to ensure that staff cashes the checks and immediately deposits the funds into individual #1's account. Per Staff #4, staff #3 only documents funds deposited and received, via check's written to staff #2, into individual #1's large account financial record once a week. There is no agency management oversite to manage what staff #2 does with large sums of money on the days and/or weeks between the checks being written to her and when she deposits money into the individual's financial account at the home.
Staff person #4 reported to the department on 10/15/2020 that individual #1 does not have a debit or credit card. According to individual #1's August 2020 large financial account record, staff person #2 had many items purchased and delivered to her home. These items were purchased with a credit/debit card which Individual #1 did not have. However, funds were taken from Individual #1 account to reimburse staff #2 for purchases made in August 2020. Examples of when staff #2 used a Mastercard to purchase items, had the items delivered to her personal home location, then reimbursed herself from individual #1's funds was: 8/20/2020 Amazon purchase $28.99, 8/13/2020 Amazon purchase $29.64, 8/7/2020 Amazon purchase $12.43, 8/9/2020 Dollar general store purchase $8.42, 7/28/2020 Lakeside purchase for 9.53, 7/13/2020 amazon purchase for $143.76.
Staff #2 said the 3 Individuals at the home chose to pay for Netflix three months at a time and they rotate. There is no evidence that the individuals agreed to the specific Netflix package. The agency could not provide the department with documentation of what package the individuals at the home are paying for, how much per month it was, who was responsible for paying the bill, and who's name is on the Netflix account. Staff #2 reported that she receives the emails about the Netflix account, not any of the individuals in the home. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | All Supervisors and Program Specialists were retrained, as well as the rep payees, that checks will no longer be written out to the house supervisor, but they will be addressed to the individual, unless otherwise in the ISP. If the check cannot be picked up in a timely manner proper documentation will be made to as to why. This will allow the individual to be part of the banking process. The house supervisor will also make a copy of the check. The house supervisor will continue to complete weekly audits. The program Specialist will continue to contact all rep payees and ensure all checks written to the Individuals are accounted for when completing quarterly audits. If an individual refuse to go to the bank there will be documentation in the ISP, which will be updated by the Program Specialist. Audit forms that were completed through the year are attached to show that the accounts are monitored. The agency policy is to be adhered to at all times. Completed: 10/26/2020
The Arc is going to acquire a Netflix account for the individuals at 340 Meadow Lane. The annual letter of expenses was reviewed with the individual and she will now pay the Arc for the Netflix package. The supervisor will no longer use Netflix gift cards. Completed: 11/1/2020 |
11/01/2020
| Implemented |
| 6400.32(u) | Individual has the right to make healthcare decisions. Individual #1's mother, who is not legal guardian is making medical decisions There is a POLST (Pennsylvania Orders for Life Sustaining Treatment) that had been signed on 2/27/2018 by Individual #1's mother- who is not the legal guardian for DNR. Individual#1 did not sign this form and was not part of this decision-making regarding health decisions. | An individual has the right to make health care decisions. | The Individual and team have discussed future healthcare planning. The individual acquired a Medical Power of Attorney paperwork having her mother and sister as health care designees in case she is no longer able to make such decisions for herself. It was also notarized. All supervisors and program specialists were retrained on the purpose of these documents to include the individual and if anyone has a POLST form that they are updated every year and include the individuals input. Completed: 10/26/2020 |
10/26/2020
| Implemented |
| 6400.46(b) | At the time of the 10/14/2020 annual inspection, Staff person #1 received training in the fire safety requirements of this regulation on 6/11/19 and not again since then, outside the annual time frame. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | 46b: Attached is the Staff person #1 received training in the fire safety requirements. The training department had the documents but only sent what was the training year at the time. Due to the move of the new office the current training year was not unpacked. Enclosed is the documentation that the training was completed. Completed: 10/16/2020 |
10/16/2020
| Implemented |