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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There were no scissors in the first aid kit at the time of the inspection. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | During the on site walk through, the scissors were not in the first aid kit due to a staff using them to replace gauze during wound care. The scissors were on site and replaced when the staff were finished using them. A first aid kit review is included on the back of the monthly fire drill documentation and staff complete this review. On 3/18/21 and 3/22/21, all ID Management was retrained on the location and requirement of the first aid kit checklist. The First Aid Kit Checklist will be retrained by staff at all sites by 4/16/2021. |
04/12/2021
| Implemented |
| 6400.34(a) | The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 03/15/2021 annual inspection, Individual #1 was never informed of the individuals rights as described in 6400.32. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | FSI Individual Consents/Rights were updated on 3/18/2021. On 3/18/21 and 3/22/2021, all ID Management was trained on the updates to the form. Training of the updates will be completed by staff at all sites by 4/16/2021. The updated Individual Consent/Rights will be reviewed with and signed by individuals and mailed out for guardians review and signatures by 4/16/2021. |
04/16/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The first aid kid did not contain antiseptic. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | 1. Antiseptic was obtained and placed in the first aid kit at the 1160 Foot of Ten Rd location on 3/8/19.
2. All Program Specialists were retrained on the first aid kit/manual regulation requirements on 3/7/19.
3. A new Training and Compliance Officer has been hired with a start date of 3/25/19.
4. Once initial training is completed, the Training and Compliance Officer will work in conjunction with the ID Program Team to develop a Site Coordinator training to include all aspects of the job. Site Coordinator training development completion date is projected for 4/26/19.
5. Site Coordinator training will be presented once weekly to all 10 Site Coordinators to cover a variety of topics which will include their responsibility in assuring first aid kits are stocked as per regulations. Site Coordinator training completion date is projected for 5/31/19. |
03/08/2019
| Implemented |
| 6400.113(a) | Individual #1 moved into the home 09/23/17, and did not receive fire safety training until 04/03/18. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | 1. All Program Specialists were retrained on regulations surrounding fire safety on 3/7/19.
2. All staff will be retrained on fire safety and regulations surrounding fire safety at a scheduled monthly training on 4/3/19.
3. The individual¿s residential fire safety training will be completed again prior to 4/2/19.
4. A new Training and Compliance Officer has been hired with a start date of 3/25/19.
5. Once initial training is completed, the Training and Compliance Officer will work in conjunction with the ID Program Team to develop a Site Coordinator training to include all aspects of the job. Site Coordinator training development completion date is projected for 4/26/19.
6. Site Coordinator training will be presented once weekly to all 10 Site Coordinators to cover a variety of topics which will include their responsibility in assuring fire safety trainings for individuals are completed as per regulations. Site Coordinator training completion date is projected for 5/31/19. |
04/02/2019
| Implemented |
| 6400.181(a) | Individual #1's date of admission was 9/23/2017. An initial assessment was not completed by 60 calendar days after the admission date nor was there a current assessment completed. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | 1. Individual¿s initial assessment was completed on 11/20/17 but was not in his record during licensing.
2. Individual¿s current assessment was completed on 3/8/19.
3. All Program Specialists were retrained on due dates of assessments on 3/7/19. This included initial assessments within 60 days of intake, annual assessments and amendments to assessments.
4. All documents, including ISP reviews, Assessments, Track Changes to the ISPs as per 6400, 6500 and 2380 regulations will be up to date by 6/30/19.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 12pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
7. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17. |
03/08/2019
| Implemented |
| 6400.186(a) | The ISP review for the period ending 06/24/18 was not completed until 10/23/18. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | 1. All Program Specialists were retrained on due dates and grace periods of ISP reviews (or quarterly reports) on 3/7/19.
2. As of 1/1/19, all ISP reviews are to be completed in monthly form and within 15 days of the end of month as per the ISP date. This keeps the entire team up to date on an individual¿s progress and needs.
3. The individual¿s quarterly ISP reviews were completed on 3/21/19 and signed by him on 3/22/19.
4. All documents, including ISP reviews, Assessments, Track Changes to the ISPs as per 6400, 6500 and 2380 regulations will be up to date by 6/30/19.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 12pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
7. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17. |
03/22/2019
| Implemented |
| 6400.186(b) | Individual #1 did not sign or date the ISP reviews. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | 1. All Program Specialists were retrained on signature requirements of ISP reviews (or quarterly reports) on 3/7/19. Review of the report and signature of the individual must be obtained prior to sending the review out to the team.
2. As of 1/1/19, all ISP reviews are to be completed in monthly form and within 15 days of the end of month as per the ISP date. This keeps the entire team up to date on an individual¿s progress and needs.
3. The individual¿s quarterly ISP reviews were completed 3/21/19 and signed by him on 3/22/19.
4. All documents, including ISP reviews, Assessments, Track Changes to the ISPs as per 6400, 6500 and 2380 regulations will be up to date by 6/30/19.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 12pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
7. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17. |
03/22/2019
| Implemented |
| 6400.213(6) | Individual #1's record did not contain an initial or annual assessment. | Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment).
| 1. Individual¿s initial assessment was completed on 11/20/17 but was not in his file at the time of licensing.
2. Individual¿s current assessment was completed on 3/8/19.
3. All Program Specialists were retrained on due dates of assessments on 3/7/19. This included initial assessments within 60 days of intake, annual assessments and amendments to assessments.
4. All documents, including ISP reviews, Assessments, Track Changes to the ISPs as per 6400, 6500 and 2380 regulations will be up to date by 6/30/19.
5. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
6. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 12pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
7. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17. |
03/08/2019
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-assessment was not done 3-6 months prior to expiration date. Self-assessment was completed on 4/16/2015 and expiration date was 6/30. The self-assessment should have been completed by 3/30. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Program Director is responsible for correcting the problem. There is no fix to the immediate problem.
In response to the violation of 55 PA Code Chapter 6400.15(a) on June 30, 2015 all Program Specialists were retrained on the requirements of this chapter, including the need to complete all self assessments of each home the agency operates 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance. Family Services strives to create ongoing compliance, and completes regular and ongoing checks for compliance by using the self assessment tool. In the future, all official self-assessments will be completed within the designated time frames. Program Director, upon receipt of the licenses, will inform all Program Specialists of the need to complete the self-assessment, and the due date for those. See documentation of training (FOT Attachment #2)
In order to prevent future occurrence, all Program Specialists were re-trained on completion of self assessments.
There is no document available for proof of ongoing compliance due to no self assessments needing completed until next year, 2016.
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06/30/2015
| Implemented |
| 6400.67(a) | The window in the bathroom near the lving room needs repaired/replaced. The white wooden trim around window needs painted and is peeling. The brown wooden trim around window has mold spots. The blind covering window is full of mold. | Floors, walls, ceilings and other surfaces shall be in good repair. | The maintenance team is responsible for correcting the problem. To fix the immediate problem:
1. A maintenance request was sent by Director of Training and Compliance on 5/11/15 at 9:55AM outlining the violation and requesting a correction.
2. Maintenance team cleaned and repainted the window on 5/13/2015. Attached is a photograph of before and after (FOT Attachment #1).
Following discovery of violation of 55 PA Code Chapter 6400.67(a) a training was held with all Program Specialists on 7/1/2015 around the requirements of this chapter, specifically covering information around Physical Sites and the expectations that lie within 6400 regulations in regard to floors, walls, ceilings and other surfaces being kept in good repair. Expectations outlined which cover completing walk through while on site for house meetings and monitoring visits to ensure compliance with this chapter (FOT Attachment #2).
In order to prevent future occurrence, the training was held and new expectations were outlined with all Program Specialists who serve Residential/Day Program settings.
All Program Specialists will complete walk through of all cites falling under 6400 regulations prior to July 15, 2015 to ensure that all floors, walls, ceilings and other surfaces are in good repair. If any area is found to be in non-compliance it will be corrected no later than August 31, 2015.
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06/30/2015
| Implemented |
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