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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.181(e)(4) | Individual #1's assessment, completed 11/03/2025, documented he can be outside of eyesight supervision up to 30 minutes while in the building. On 1/21/2026 Program Specialist #1 and Program Specialist #2 stated that Individual #1 needs to be within eyesight supervision at all times. Individual #2's assessment, completed 3/10/2025, documented he can be outside of eyesight supervision up to 15 minutes while in the building. On 1/21/2026 Program Specialist #1 and Program Specialist #2 stated that Individual #2 needs to be within eyesight supervision at all times. Individual #4's assessment, completed 9/09/2025, documents the individual can frequently be outside of eyesight supervision for up to 30 minutes while in the building. The assessment also documents the individual needs physical assistance in evacuating, is unable to move away from heat sources, and has physical limitations with hygiene. Individual #4's individual support plan, last updated 6/10/2025, documents the individual should be within hearing distance of staff at all times while in the building. | The assessment must include the following information: The individual¿s need for supervision. | The previous program specialist did not ensure that the ISP was updated after the annual assessment and that the information in the assessment is accurate.
Addendums to the assessments mentioned above have been made to accurately describe supervision needs for each individual. The changes have been emailed to the appropriate Supports Coordinators asking for changes to be made to the ISPs to reflect the information that is in the assessments. Program Specialists will be sending weekly emails to the Supports Coordinators until the information is updated and accurate in the ISPs. |
01/28/2026
| Implemented |
| 2380.182(c) | Individual #1's individual support plan, last updated 10/20/2025, documents the individual needs visually monitored around all heat sources, needs full physical assistance to evacuate during fire drills, and needs verbal prompting to avoid poisonous materials. Individual's assessments completed 6/04/2025 and 11/03/2025 documents he independently avoids heat sources, needs verbal prompting on using alternate exits during fire drill evacuation, and frequently avoids ingesting poisonous materials. Individual #2's individual support plan, last updated 11/05/2025 documents the individual needs physical assistance to evacuate during fire drills. Individual #2's assessment completed 3/10/2025 documents the individual evacuates with verbal prompting. Individual #3's individual support plan, last updated 1/15/2026, does not include the individual's need for supervision. Individual #3's assessment, completed 4/09/2025, documents the individual can be outside of eyesight supervision for up to 30 minutes while in the building. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The previous program specialist did not ensure that the ISP was updated after the annual assessment and that the information in the assessment is accurate.
Addendums to the assessments mentioned above have been made to accurately describe supervision needs for each individual. The changes have been emailed to the appropriate Supports Coordinators asking for changes to be made to the ISPs to reflect the information that is in the assessments. Program Specialists will be sending weekly emails to the Supports Coordinators until the information is updated and accurate in the ISPs. |
01/29/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(9) | Individual #1's physical examination, completed 1/31/17, did not include: Allergies or contraindicated medications, this section was blank. | The physical examination shall include: Allergies or contraindicated medication. | Individual #1's physical examination, completed 1/31/17, did not include: Allergies or contraindicated medications, this section was blank.( 55 PA Code Chapter 2380.111(c)(9 ) Individual #1¿s next yearly physical exam is schedule for 2/01/18. We have attached a current medication list that includes her allergies and any contraindicated medications to the physical dated 1/31/17 while awaiting the new physical exam form.
All individuals¿ physicals in the 2380 program will be reviewed by the Program Specialist and Vocational Director no later than 1/19/18. Any areas of noncompliance will be addressed following the new procedures. Both the Vocational Director and Program Specialists will be trained on the new procedure by Cynthia L. Dias by 1/19/18. Greene Arc will implement the following procedures to ensure all physicals are completed in their entirety going forward. All physical forms will be reviewed by the Program Specialist and the Vocational Director within 7 business days of being received. When blanks appear on an individual¿s physical form the physical form will be faxed back to the physician¿s office with a request that all categories must be completed. The original fax with the request for information from the physicians¿ office will be attached to the physical as evidence that Greene Arc did attempt to have the missing information completed by the physician. If there is no response within 10 days a second attempt will be made. This fax sheet will also be attached to the physical. The group home staff/ family will also be contacted and asked to obtain the necessary information. This request will also be documented via email or mailed correspondence and attached to the physical. All supporting correspondence will be kept in the participant¿s file. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff in the aforementioned process in their responsibilities in ensuring all individuals' physical examination included all required information and there are not any required areas left blank. Documentation of trainings shall be kept. (AS 1/19/18)] |
01/19/2018
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination, completed 1/31/17, did not include: Medical information pertinent to diagnosis and treatment in case of an emergency, this section was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's physical examination, completed 1/31/17, did not include: Medical information pertinent to diagnosis and treatment in case of an emergency, this section was blank.(55 PA Code Chapter 2380.111(c)(10) Individual #1¿s next yearly physical exam is schedule for 2/01/18. We have requested that the group home obtain from the physician written documentation of medical information pertinent to diagnosis and treatment in case of an emergency and when it is received we will attach it to the physical dated 1/31/17 while we await the completion of a new physical. All individuals¿ physicals in the 2380 program will be reviewed by the Program Specialist and Vocational Director no later than 1/19/18. Any areas of noncompliance will be addressed following the new procedures. Greene Arc will implement the following procedures to ensure all physicals are completed in their entirety going forward. Both the Vocational Director and Program Specialists will be trained on the new procedure by Cynthia L. Dias, Executive Director by 1/19/18. Greene Arc will implement the following procedures to ensure all physicals are completed in their entirety going forward. All physical forms will be reviewed by the Program Specialist and the Vocational Director within 7 business days of being received. When blanks appear on an individual¿s physical form the physical form will be faxed back to the physician¿s office with a request that all categories must be completed. The original fax with the request for information from the physicians¿ office will be attached to the physical as evidence that Greene Arc did attempt to have the missing information completed by the physician. If there is no response within 10 days a second attempt will be made. This fax sheet will also be attached to the physical. The group home staff/ family will also be contacted and asked to obtain the necessary information. This request will also be documented via email or mailed correspondence and attached to the physical. . All supporting correspondence will be kept in the participant¿s file.[Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff in the aforementioned process in their responsibilities in ensuring all individuals' physical examination included all required information and there are not any required areas left blank. Documentation of trainings shall be kept. (AS 1/19/18)] |
01/19/2018
| Implemented |
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