| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(10) | Individual #1's physical examination completed 6/30/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination completed 7/8/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Wesley Family Services IDD policy #04.01 INDIVIDUAL HEALTH, states "the physical exam will be completed in its entirety, without blanks..... Site supervisors/Program Specialists will review the document to ensure accuracy."
Additionally, a new Physical form was revised to ensure inclusion of Medical information pertinent to diagnosis and treatment in case of emergency. This was accidentally omitted. |
10/01/2021
| Implemented |
| 2380.181(a) | Individual #2 had an annual assessment completed 8/13/20 and then again 9/13/21. | 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. | Due to some changes in services during COVID, there was some confusion regarding the bulletin regarding new admission assessments and returning to program. We believed a person was considered a new admission if they returned after 7/1/21 and would follow the new admission assessment criteria. We now completely understand that they are not considered a new admission. |
10/01/2021
| Implemented |
| 2380.38(b)(2) | Direct Service Worker #1, date of hire 4/19/21 and first date working with Individuals 4/26/2021, was provided training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 5/18/21. Direct Service Worker #2, date of hire 5/10/21 and first day working with Individuals 5/25/21, was provided training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 6/8/21. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | A revised training plan was developed and implemented immediately indicating the first day trainings, prior to working with individual trainings, must complete within 30 days, etc. |
10/01/2021
| Implemented |
| 2380.38(b)(3) | Direct Service Worker #1, date of hire 4/19/21 first started worked with Individuals 4/26/2021, was provided training on Individual Rights on 5/5/21. | The orientation must encompass the following areas: Individual rights. | A revised training plan was developed and implemented immediately indicating the first day trainings, prior to working with individual trainings, must complete within 30 days, etc. |
10/01/2021
| Implemented |
| 2380.38(b)(4) | Direct Service Worker #1, date of hire 4/19/21 first started working with Individuals 4/26/2021, was provided training on recognizing and reporting incidents 5/3/21. | The orientation must encompass the following areas: Recognizing and reporting incident. | A revised training plan was developed and implemented immediately indicating the first day trainings, prior to working with individual trainings, must complete within 30 days, etc. |
10/01/2021
| Implemented |