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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The thermometer located within the home's first aid kit could not be made to function during the onsite 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. | The nonfunctional thermometer was replaced immediately after the inspection. |
10/02/2024
| Implemented |
| 6400.110(f) | Individual #2 and Individual #3 are deaf. The home is equipped with flashing alarms to ensure that the individuals are alerted in the event of a fire. Staff on site reported that both individuals access the home's garage on occasion. An audible smoke detector was present in the garage; however, there was no flashing alarm within the garage and no flashing alarm within the rest of the home with a flash that could be seen from within the garage. As such, if the individuals were in the garage when a fire occurred, they would not be promptly alerted to evacuate the home. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | A flashing alarm was installed immediately after the inspection was completed. |
10/02/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On July 16, 2022, Individual #1 was walking around the individual's home and had gone into the kitchen and taken goldfish crackers from the cabinet. Staff #1 was aware that Individual #1 was awake and walking around the home. Staff #1 discovered Individual #1 in the kitchen with the goldfish crackers and took them out of his hand, causing some to drop on the floor. Individual #1 returned to his bedroom. Staff #1 remained in the kitchen to clean up the crackers that had fallen on the floor. Staff #1 went into Individual #1's bedroom and found Individual #1 sitting on his bed. Staff #1 told Individual #1 to "stop it" and left Individual #1's room and returned to assisting another individual in the home. When Staff #1 returned to administer medication approximately 30 minutes later to Individual #1, Staff #1 found Individual #1 laying on the bed struggling to breathe. Individual #1 had a history of aspiration and had a safe eating protocol in place.
Individual #1's Individual Service Plan states: Individual #1 is recommended to follow regular chopped diet with thin liquids, requires staff supervision while eating and is not allowed to lay down for at least 30 minutes due to being a risk for aspiration. A food protocol is in place to ensure that Individual #1 does not cheek his food and swallows his food after every bite. Staff have signs to utilize for Individual #1 to slow down, wait and swallow. Staff are to stay with Individual #1 while the individual is eating (sit next to him), staff are to cut his food into ½ inch by ½ inch pieces and make sure Individual #1 is eating slowing and swallowing each bite prior to taking another. Staff must provide prompting during the entire time he is eating his meal/snack."
Individual #1 was neglected when Staff #1 did not follow Individual #1 to the kitchen to ensure that the Individual was not eating without supervision. Upon the discovery of Individual #1 with goldfish crackers, Staff #1 did not ask Individual #1 if the Individual had eaten any of the goldfish crackers. Staff #1 did not check to ensure that Individual #1 did not pocket any goldfish crackers in the individual's cheek. Staff #1 did not check to ensure that Individual #1 had swallowed any goldfish crackers that the individual may have eaten. Staff did not encourage Individual #1 to swallow anything that may have been in the Individual's mouth upon discovering the Individual in the kitchen. Staff #1 did not ensure that Individual #1 did not lay down for 30 minutes after potentially eating goldfish crackers. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | #1- Action-At the Sterley Street Program any current food/safe eating protocols will be reviewed with all Sterley Street employees. The training/review will consist of a thorough, step by step breakdown of the protocol. Any additional training, required to understand and implement the steps/actions in the protocol will be completed (i.e., learning the signs for slow down, wait, and swallow, demonstration of food consistency, size, etc.) An opportunity for questions and further explanation will occur to ensure understanding. Discussion on problem solving should be included in the training. Problem solving should be considered discussion on prioritizing care and actions based on the participants health, safety, and welfare, especially when working alone. An attendance sheet/acknowledgement of responsibility form will be signed and dated by each employee following completion of the training. The attendance sheet will be forwarded to the Office Coordinator to input into Training Manager, Prospectus Associates, Inc.¿s method of maintaining employee training.
Owner- Carol Morgan- Program Supervisor
Melissa Heckart- Program Director
#2- Provide training on Abuse/Neglect. Training should also focus on abuse/neglect as related to protocols and application of those protocols.
Owner- Carol Morgan- Program Supervisor
Melissa Heckart- Program Director
Ms. Morgan and Ms. Heckart will work together to accomplish the Action listed above including implementation of training as well as completion of training documentation followed up by forwarding training documentation to the Office Coordinator.
#3- Action - All current food/safe eating protocols will be reviewed with all employees supporting the participants at this time at all Prospectus Associates, Inc. programs. The training/review will consist of a thorough, step by step breakdown of the protocol. Any additional training, required to understand and implement the steps/actions in the protocol, will be completed (i.e., learning the signs for slow down, wait, and swallow, demonstration of food consistency, size, etc.) An opportunity for questions and further explanation will occur to ensure understanding. Discussion on problem solving should be included in the training. Problem solving should be considered discussion on prioritizing care and actions based on the participants health, safety, and welfare, especially when working alone. An attendance sheet/acknowledgement of responsibility form will be signed and dated by each employee following completion of the training. The attendance sheet will be forwarded to the Office Coordinator to input into Training Manager, Prospectus Associates, Inc.¿s method of maintaining employee training. |
10/01/2022
| Implemented |
| 6400.70 | The home did not have an operable, non-coin-operated telephone with an outside line that is easily accessible to individuals and staff persons. On July 16, 2022, when Staff #1 attempted to contact 911, Staff #1 discovered that the phone in the home was not working. Information provided about the phone indicated that the phone is an internet-based phone and works differently than a traditional land line phone in that when calling out, the phone number being called needs to be dialed and then the call button pressed, and Staff #1 was unaware of how to utilize the phone making the phone inaccessible to the staff at the time of the incident. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| #1- Action- An initial explanation/training will be provided by the program supervisor for all employees at the Sterley Street Program addressing ¿making an internet-based phone call.¿ This training can be done verbally and/or by providing written directions. Employees should sign an attendance sheet upon completion of and understanding on how to make an internet-based phone call. The attendance form should be forwarded toe the Office Coordinator for input into training manager. Program Director will review training documentation for completion.
Owner- Carol Morgan (Program Supervisor)
Melissa Heckart (Program Director)
#2- Action- Specific directions on proper use of an internet-based phone will be sent out to all programs. The directions will be posted by each phone and/or a label with the directions will be applied to the handset.
Owner- IT Department
Jonathan Colon- Chief Operations Officer
Completion Date- August 11, 2022 |
09/19/2022
| Implemented |
| 6400.52(c)(1) | Staff #1did not receive annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | #1- Action - In combination with Training Manager, Prospectus Associates, Inc. utilizes the College of Direct Support for training. Staff #1 CDS training was collected and documented on 6/29/2022.The specific training listed was completion of ¿Person-Centered Planning- Lesson One-Foundations of Person-Centered Planning; Lesson Two: An Overview of Person-Centered Approaches; Lesson Three-The Person-Centered Planning Process; Lesson Four- Bringing Person Centered Plans to Life; You¿ve Got a Friend: The Importance of Relationships; You¿ve Got a Friend: Barriers, Challenges and Opportunities to Making Friends. These areas of training were completed on 6/29/2022. |
06/29/2022
| Implemented |
| 6400.52(c)(2) | Staff #1 did not receive annual training in 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 Service Law (23 Pa.C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704) and applicable adult protective services regulations. | The annual training hours specified in subsections (a) and (b) 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. | Included in Staff#1¿s Training Manager report was completion of: Incident Management Bulletin Introduction Webinar presented by ODP; Incident Management Bulletin Overview Webinar-Presented by ODP; Incident Management Bulletin Recognizing Incidents- Presenter ODP. This training encompasses 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. Staff #1 complete the Incident Management training provided by ODP for a total of 7 hours of training and completed on 8/17/2021. |
08/17/2021
| Implemented |
| 6400.52(c)(3) | Staff #1did not receive annual training in Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | #1- Action - In combination with Training Manager, Prospectus Associates, Inc. utilizes the College of Direct Support for training. Staff #1 CDS training was collected and documented on 6/29/2022.The specific training listed was completion of Individual Rights and Choice: Overcoming a Past of Barriers and Restrictions; Individual Rights and Choice: Restrictions of Individual Rights; Individual Rights and Choice: Your Role in Supporting Expression of Rights and Facilitating Choice Making. |
06/29/2022
| Implemented |
| 6400.52(c)(5) | Staff #1did not receive annual training in the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | #1- Action ¿ A Professional Development Attendance Form was signed by Staff #1 along with other Program DSPs in May 2022 for Review of Current Eating Protocol for Individual #1. This information will be provided.
#2- Action- At the Sterley Street Program all current ISP¿s and SEEP¿s (Behavior Supports) will be reviewed with all Sterley Street employees. The training/review will consist of a thorough review of the ISP¿s and SEEP¿s. Any additional training, required to understand and implement the ISP and SEEP¿s (Behavior Supports) will be completed. An opportunity for questions and further explanation will occur to ensure understanding. An attendance sheet/acknowledgement of responsibility form will be signed and dated by each employee following completion of the training. The attendance sheet will be forwarded to the Office Coordinator to input into Training Manager, Prospectus Associates, Inc.¿s method of maintaining employee training.
Owner- Carol Morgan- Program Supervisor
Melissa Heckart- Program Director |
10/01/2022
| Implemented |
| 6400.186 | Individual #1's plan was not implemented on July 16, 2022. Individual #1's ISP states "the individual is to follow a safe eating protocol. Individual #1 is recommended to follow regular chopped diet with thin liquids and is not allowed to lay down for at least 30 minutes due to being a risk for aspiration. A food protocol is in place to ensure that Individual #1 does not cheek his food and swallows his food after every bite. Staff have signs to utilize for Individual #1 to slow down, wait and swallow. Staff are to stay with Individual #1 while the individual is eating (sit next to him), staff are to cut his food into ½ inch by ½ inch pieces and make sure Individual #1 is eating slowing and swallowing each bite prior to taking another. Staff must provide prompting during the entire time he is eating his meal/snack."
On July 16, 2022, Staff #1did not implement Individual #1's ISP and Safe Eating Protocol. Staff #1 did not ask Individual #1 if the individual had eaten any of the goldfish crackers after discovering the individual in the kitchen with the goldfish crackers in the individuals' hand. Staff #1 did not check to ensure that Individual #1 did not pocket any goldfish crackers in the individual's cheek. Staff #1 did not check to ensure that Individual #1 had swallowed any goldfish crackers that the individual may have eaten. Staff #1 did not sit next to Individual #1 while Individual #1 may have been eating goldfish crackers and Staff #1 did not ensure that Individual #1 did not lay down for 30 minutes after potentially eating goldfish crackers. | The home shall implement the individual plan, including revisions. | #1- Action-At the Sterley Street Program any current food/safe eating protocols will be reviewed with all Sterley Street employees. The training/review will consist of a thorough, step by step breakdown of the protocol. Any additional training, required to understand and implement the steps/actions in the protocol will be completed (i.e., learning the signs for slow down, wait, and swallow, demonstration of food consistency, size, etc.) An opportunity for questions and further explanation will occur to ensure understanding. Discussion on problem solving should be included in the training. Problem solving should be considered discussion on prioritizing care and actions based on the participants health, safety, and welfare, especially when working alone. An attendance sheet/acknowledgement of responsibility form will be signed and dated by each employee following completion of the training. The attendance sheet will be forwarded to the Office Coordinator to input into Training Manager, Prospectus Associates, Inc.¿s method of maintaining employee training.
Owner- Carol Morgan- Program Supervisor
Melissa Heckart- Program Director |
10/01/2022
| Implemented |
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