| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(4) | The physical examination for Individual #3 did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Attachment 10a is Individual 3¿s most recent physical examination in which the Physician indicates the patient is unable to complete these screenings. Attachment 10b is a consumer physical completed since licensing that is compliant. PS will begin to use the physical checklist used by our residential programs upon receipt of physical to maintain future compliance. Attachment 10c is the checklist completed for physical identified as 10b. Attachment 12 is signature sheet from staff training and summary of topics covered. |
09/17/2015
| Implemented |
| 2380.111(c)(5) | Individual #2's date of entry was 12/3/14 and a tuberculin skin test was not completed until 3/19/15. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | The physical for our most recent admission is attachment 11a. The ICE form indicating date of admission is attachment 11b. The TB test for this individual was completed prior to admission. Facility director has been tasked for reviewing all new admission paperwork for consumers in order to maintain future compliance. Written authorization from the facility director must be in the individual¿s record prior to start date. This authorization will be based on compliance with admission criteria. Attachment 12 is signature sheet from staff training and summary of topics covered. |
09/17/2015
| Implemented |
| 2380.128(a) | Staff #5 completed medication administration training on 4/4/14 and not again until 4/10/15. | A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | This noncompliance was the result of a transcription error made by our previous medication trainer. Our current trainer used incorrect information in establishing the recertification date. In order to maintain future compliance, we have audited all current medication administration records to insure that correct recertification dates are noted based on previous year¿s certification. Attachment 9a is the results of our audit. Attachments 9b and 9c represent the training records for a staff who has been recertified since our licensing inspection in compliance. |
09/17/2015
| Implemented |
| 2380.173(9) | The Individual Support Plan (ISP) for Individual #2 stated that he was allergic to Topamax and Valporic Acid. Individual #2's physical and assessment does not note that he is allergic to any medications. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | Attachment 8a is an updated physical for Individual 2 that includes updated drug allergies. Attachment 8b is an addendum to individual¿s assessment with drug allergies. The updates included a 3rd, new allergy that will require an ISP update. Attachment 8c is communication to the SC regarding this update. Attachment 7a, 8d, and 10a represent an assessment, ISP, and physical that consistently list medication allergies. Assessment will be reviewed by PS Supervisor to measure ongoing compliance. This includes auditing against consumer physical and ISP for consistency. Attachment 12 is signature sheet from staff training and summary of topics covered. |
09/17/2015
| Implemented |
| 2380.181(a) | Individual #4 had an assessment completed on 4/2/14 and not again until 5/9/15. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Attachment 6a is an assessment completed since licensing. Attachment 6b is the prior assessment for the same individual showing compliance. This regulation was included in training for our 2380 Program Specialists in order to maintain future compliance. Confusion existed regarding annual completion of assessment and the expectation to provide to SC 30 days in advance of meeting. It was clarified that the expectation is at least 30 days prior to annual review, therefore both standards can be met while maintaining compliance. Attachment 12 is signature sheet from staff training and summary of topics covered. |
09/17/2015
| Implemented |
| 2380.181(e)(13)(ii) | The assessment for Individual #3 did not include progress and growth in the area of motor and communication skills. | 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. | Individual 3¿s assessment has been updated. Attachment 7a is his current assessment and addendum with update. Attachment 6a is an assessment completed since licensing. Attachment 6b is the prior assessment for the same individual. These show change year-after-year in the sections cited in Individual 3¿s assessment. This regulation was included in training for our 2380 Program Specialists in order to maintain future compliance. PS Supervisor previously reviewed current year assessments. Moving forward, they will review current and previous to measure compliance across documents. Attachment 12 is signature sheet from staff training and summary of topics covered. |
09/17/2015
| Implemented |
| 2380.181(e)(13)(iii) | The assessment for Individual #3 did not include progress and growth in the area of personal adjustment. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Individual 3¿s assessment has been updated. Attachment 7a is his current assessment and addendum with update. Attachment 6a is an assessment completed since licensing. Attachment 6b is the prior assessment for the same individual. These show change year-after-year in the sections cited in Individual 3¿s assessment. This regulation was included in training for our 2380 Program Specialists in order to maintain future compliance. PS Supervisor previously reviewed current year assessments. Moving forward, they will review current and previous to measure compliance across documents. Attachment 12 is signature sheet from staff training and summary of topics covered. |
09/17/2015
| Implemented |
| 2380.183(4) | Individual #2 received 1:1 staff to individual ratio while at day program. Individual #2's Individual Support Plan (ISP) did not state a supervision level for Individual #2 nor did it have a protocol and method of evaluation used to determine progress towards more unsupervised time. | The ISP, including annual updates and revisions under § 2380.186 (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. | The ISP for Individuals 2 and 3 have had pertinent sections reviewed and updated with the SC. Attachment 2a and 2b represent the review and changes to the supervision section of the ISP. Attachment 2c and 2d represents the communication of these changes to the SC. Attachment 2e represents a plan approved since licensing that includes review of these sections. All plans, based on consumer participation in 2380 or 6400 programming, will be reviewed internally by a PS Supervisor prior to submission to SC in order to maintain future compliance. These reviews are done electronically using the `track changes¿ function and stored within each consumer¿s electronic record. Attachment 12 is signature sheet from staff training and summary of topics covered. |
09/17/2015
| Implemented |
| 2380.183(7)(i) | Individual #2's Individual Support Plan (ISP) did not have an assessment of their potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | Individual 2¿s plan has been updated. See attachment 4a. Attachment 2c is a copy of email to SC with the pertinent updates. Attachment 4b is an example of a consumer review completed since licensing that is in compliance. All plans, based on consumer participation in 2380 or 6400 programming, will be reviewed internally by a PS Supervisor prior to submission to SC in order to maintain future compliance. These reviews are done electronically using the `track changes¿ function and stored within each consumer¿s electronic record. Attachment 12 is signature sheet from staff training and summary of topics covered. |
10/31/2015
| Implemented |
| 2380.183(7)(iii) | Individual #2's Individual Support Plan (ISP) did not have an assessment of their potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | Individual 2¿s plan has been updated. See attachment 5a. Attachment 2c is a copy of email to SC with the pertinent updates. Attachment 4b is an example of a consumer review completed since licensing that is in compliance. All plans, based on consumer participation in 2380 or 6400 programming, will be reviewed internally by a PS Supervisor prior to submission to SC in order to maintain future compliance. These reviews are done electronically using the `track changes¿ function and stored within each consumer¿s electronic record. Attachment 12 is signature sheet from staff training and summary of topics covered. |
10/31/2015
| Implemented |
| 2380.186(b) | Individuals #1-#4 did not date any of their Individual Support Plan (ISP) reviews upon review of their ISP. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | We have used the Licensing Inspection Instrument provided by the Department to guide our forms and expectations with this regulation. The LII does not indicate that a consumer must also date the review. This language is contained within the PA Code. This clarification was included in training for our 2380 Program Specialists in order to maintain future compliance. Attachment 1a is Individual 3¿s most recent review and attachment 1b is another consumer review done since our inspection in compliance. Attachment 12 is signature sheet from staff training and summary of topics covered. |
10/31/2015
| Implemented |
| 2380.186(c)(2) | The Individual Support Plan (ISP) reviews for Individual #2 and #3 did not review their 1:1 staff to individual ratio supervision levels. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The ISP for Individuals 2 and 3 have had pertinent sections reviewed and updated with the SC. Attachment 2a and 2b represent the review and changes to the supervision section of the ISP. Attachment 2c and 2d represents the communication of these changes to the SC. Attachment 2e represents a plan approved since licensing that includes review of these sections. All plans, based on consumer participation in 2380 or 6400 programming, will be reviewed internally by a PS Supervisor prior to submission to SC in order to maintain future compliance. These reviews are done electronically using the `track changes¿ function and stored within each consumer¿s electronic record. Attachment 12 is signature sheet from staff training and summary of topics covered. |
10/31/2015
| Implemented |
| 2380.186(d) | Individual #2's Individual Support Plan (ISP) reviews were not sent to his school, where he is still a current student. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Individual 2¿s enclosure letter has been updated since licensing and records were sent to his school. Attachment 3a is a copy of Individual 2¿s most recent letter. Attachment 3b is a copy of another consumer¿s enclosure letter sent prior to licensing that included the individual¿s school. This was the most recent example that included a school based on our census. This regulation was included in training for our 2380 Program Specialists in order to maintain future compliance. Attachment 12 is signature sheet from staff training and summary of topics covered. |
10/31/2015
| Implemented |