Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00160969 Renewal 07/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff person #3 did not have a criminal check completed within 5 working days after the date of hire.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Going forward the Credentialing department will conduct audits on 25% of all the new hire files quarterly to ensure compliance. Please refer to attachment: A5 10/30/2019 Implemented
2380.36(f)Staff person #1 record did not have annual fire safety training. Staff person #4 record did not have annual fire safety training. Staff person #5 record did not have annual fire safety training.Program specialists and direct service workers shall be trained annually by a fire-safety expert in the training areas specified in subsection (f).Going forward, management will perform audits on 25% of the staffing body quarterly on the training hours and records of all the staff working within the 2380 program in order to remain compliant. Staff #5 did haver annual fire safety training please see attachment: A4 10/22/2019 Implemented
2380.36(g)Staff person #4 record did not have first aid and CPR training.There shall be at least one staff person for every 18 individuals, with a minimum of two staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.Going forward, management will perform audits on 25% of the staffing body quarterly on the training hours and records of all the staff working within the 2380 program in order to remain compliant. 10/22/2019 Implemented
2380.53(a)The Purell hand cleaner was located throughout the facility and was labeled to keep out of reach of the children.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.On 8/1/19, all hand dispensers containing Purell were removed from all program areas by Monica Hall ¿ Program Director. Please see attachment: A3 08/01/2019 Implemented
2380.113(a)Staff person #1's current physical exam completed on 11/29/18 was more than the 2-year required time frame from the previous physical exam completed on 11/11/16. Staff person #4's last completed physical exam was on 11/10/16, which is more than 2 years ago.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.On 10/22/19 staff were retrained on the importance of having bi-annual physical examinations and PPD screenings in order to maintain compliance. Monthly audits are completed on the anniversary dates of each staff annual physical. Notices are sent to each staff person two months before the approaching anniversary date for completion. Going forward, anyone who is out of compliance will be given notice and removed from the hourly schedule. Please see attachment: A2 10/22/2019 Implemented
2380.181(a)Individual #1's assessment was not a complete document.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.On 10/22/19, Lakeisha Murphy assessment was completed in full and meets the 2380 regulatory requirements. Program Specialist were retrained on the importance of completing all required documentation annually in order to remain compliant. Please see attachment: A1 09/10/2019 Implemented
2380.39(a)(1)Staff person #1 record did not have 24 hours of training for the completed training year. Staff person #4 record did not have 24 hours of training for the completed training year.The following shall complete 24 hours of training related to job skills and knowledge each year: Directive service workers.Going forward, management will perform audits on 25% of the staffing body quarterly on the training hours and records of all the staff working within the 2380 program in order to remain compliant. 10/22/2019 Implemented
Article X.1007Merakey Alleghany Valley School is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #2's record did not document if they had lived in Pennsylvania for the past 2 years. Staff person #3's record did not document if they had lived in Pennsylvania for the past 2 years.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Going forward the Credentialing department will conduct audits on 25% of all the new hire files quarterly to ensure compliance. Please refer to attachment: A5 10/30/2019 Implemented
SIN-00131528 Renewal 05/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)(18)All individuals attending Allegheny Valley's Tremont Day Program require ICF/MR residential care. Individuals attending the program have active seizure disorders, contagious diseases, and significant medical needs. Staff members were not been trained in seizures or follow up precautions for seizures. Individuals did not have seizure protocols. There was no documentation that staff members were trained on the medical needs of the individuals. There was no documentation that staff members were trained in behavior plans and social, emotional, environmental needs plans.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual.This citation should only reference regulatory requirement as it relates to our day program facility. Therefore, on 6-12-18 all program staff have been trained on of the individuals whom were selected as a part of the on-site inspection with seizure diagnoses. Everyone has a personalized seizure plan that address their needs as it relates to what staff need to know to support them. Going forward audits are being conducted to ensure that everyone diagnosed with a seizure disorder has an individualized plan which will be updated annually within their lifetime medical histories. Program Specialist will complete these audits by 8/30/18 and train direct service workers by 9/30/18. Going forward Program Specialists will coordinate the training of direct service workers in the content of health and safety needs relevant to everyone assigned to their caseload to include seizure disorders. This training will be conducted annually. See attachment #s S1-S11 06/12/2018 Implemented
2380.36(a)REPEATED VIOLATION - 3/11/16. Staff #5 was hired on 12/11/17 and did not receive orientation training relevant to her job duties, daily operation of the facility, or policies of the agency. Staff #6 was hired on 5/15/17 and did not receive training relevant to his job duties or daily operation of the facility.The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.Management will review the daily operations of the facility with all new hires. Going forward the first day staff is assigned to the facility he/she will be trained on the daily operations of the facility by Program Management. This training will be conducted with all new hires and annually thereafter. Program Management was trained on this process on 6/12/18 Please refer to attachment: P1 &P2. 06/12/2018 Implemented
2380.36(c)Staff #1 is the director of the facility and only had 17.75 hours of training. Staff #2 is a program specialist of the facility and only had 17.75 hours of training. Staff #3 is a direct service worker and had 1 hour of training. Staff #4 is a direct service worker and had 7 hours of training.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.Going forward staff will receive at least 3 hours of training relevant to human services monthly. The Associate Executive Director will perform an audit on the training records 9 months into training year to ensure that all staff have 24 hours of training. Any staff person who falls below 24 hours will be given additional training by the 11 month of training year to ensure compliance. This will be an annual training. See attachment #Q1. 07/30/2018 Implemented
2380.36(e)Staff #2 received fire safety training on 7/29/16 and not again until 9/25/17. Staff #3 had fire safety training on 9/25/17. There was no documentation of a 2016 training. Staff #5 and #6 received a fire safety quiz upon hire. The fire safety training did not include the requirements specified per regulation.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Program Management and Program Specialist were all trained on 6/12/18 on fire safety, evacuation procedures, responsibilities during fire drills, designated meeting place, use of fire extinguishers etc. Going forward Program Specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drill, the designated meeting place outside the building or within the fire safe area in the event of an actual fire. This will be reinstructed annually. See attachment #s : R1 to R19 06/12/2018 Implemented
2380.55(a)The black filing cabinet in Area 3 had a dried, tan substance splashed over it. The restroom in Area 5 contained used, latex gloves laying on the floor and sink. At least one individual in the program had a contagious disease. The carpet throughout the facility was very stained.Clean and sanitary conditions shall be maintained in the facility.The Inspector did not mention any individual with contagious disease during the on-site inspector nor did they mention the individual within the Plan of Correction. Therefore, it appears to be some discrepancy within this citation by the author of this document. However, the black filing cabinet in Area 3 was removed on 6/9/18. A new cabinet has been ordered to replace the mentioned cabinet on 5/11/18. See attachment #¿s N2- 11. Regarding the restroom in area 5, staff were trained on 5/18/18 through 5/21/18 on the new changing and restroom checklist. They will be check these areas three times a day to ensure that there aren¿t any used latex gloves laying on the floor/ sink areas and that the space is clean. Going forward staff will complete a Changing Room Checklist and submit results to program management daily. See attachment #O1-O2. Environmental Services is responsible for implementing a 90- day Improvement Plan to ensure cleanliness of carpet on 6/8/18. This plan was reviewed with Program Director on 6/8/18 and began implementation on the evening of 6/8/18. Program Director will meet with Environmental Service Department quarterly to discuss the progress being made on the cleanliness of the carpet. Please see attachment # O3. 06/08/2018 Implemented
2380.58(a)The walls in Area 4 were scuffed with black marks and had holes in the drywall. The cabinet was dented and a dried, brown substance was splashed on it. The black filing cabinet in Area 5 had a dented bottom drawer. The left, tan cabinet had a broken handle.Floors, walls, ceilings and other surfaces shall be in good repair.The walls in the Area 4 mentioned in citation have were repaired on 5/9/18. The cabinet mentioned in citation was clean and substance removed on 5/9/18. New cabinets were ordered on 5/11/18 to replace above mention cabinet and is currently in the process of being delivered. See attachment #¿s N1-12. Going forward Program Management will conduct Area Inspections weekly and document findings on an audit sheet weekly to tracking compliance. The audit sheets will be reviewed by Program Director weekly to address any areas of non-compliance. Program Director will submit all repair request to Maintenance Department for corrections. The maintenance department will have up to 8 weeks to correct any issue. 05/09/2018 Implemented
2380.59(a)The men's restroom, women's restroom, kitchen area, and side changing room of the main program area on the main level did not have hot water. The staff restrooms on the main level did not have hot water.The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas.A new hot water heater was purchased on 5/22/18 and installed on 5/24/18. The Program management was trained on 6-11-18 regarding the importance of having hot water accessible in the facility. Going forward, water temperatures will be done daily throughout the facility and recorded on a log. If it appears to be a problem regarding hot water; the maintenance department will be notified and a work order submitted in Skyline. Maintenance department will have up to 8 weeks for to correct the problem. See attachments # L1- L3 06/11/2018 Implemented
2380.83(a)The emergency evacuation plan did not include the means of transportation to the emergency shelter.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.Emergency Action Plan was updated to state the following: Staff will use their assigned residential vehicle to transport individual to emergency relocation site. See attachment # K1 06/11/2018 Implemented
2380.91(a)Individual #1 was admitted to the program on 8/9/17. She was not trained on fire safety until 10/2/17. Individual #7 was admitted to the program on 4/24/17. He was not trained on fire safety until 5/23/17. Individual #9 was admitted to the program on 5/8/17. He was not trained on fire safety until 5/12/17. Individual #5 and Individual #6 received fire safety training on 9/25/17 and 10/5/17, respectively. There was no training for 2016.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.Program management were trained on 6-11-18 in ensuring that all new admissions are instructed in general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting place outside the building or within the fire safe area. Please see attachment: J1. 06/11/2018 Implemented
2380.111(b)Individual #7's physical exam was not dated by the physician.The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.Program Specialists were trained on 6-11-18 regarding how to review individual physicals 30 days prior to annual meeting to ensure compliance to 2380 regulations. Audits will be conducted on a quarterly schedule. Any physical found not to be compliant, Program Specialists will notify the Medical department and team members of discovery to develop a plan to corrected area on non-compliance. This will be an annual training. See attachment # I(1) & I (2). 06/11/2018 Implemented
2380.111(c)(5)Individual #5's tuberculin testing was completed on 2/24/15 nd not again until 9/21/17.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.Program Specialists were trained on 6-11-18 regarding how to review individual physicals 30 days prior to annual meeting to ensure compliance to 2380 regulations. Audits will be conducted on a quarterly schedule. Any physical found not to be compliant, Program Specialists will notify the Medical department and team members of discovery to develop a plan to corrected area on non-compliance. This will be an annual training. See attachment # I(1) & I (2). 06/11/2018 Implemented
2380.113(a)REPEATED VIOLATION - 3/11/16. Staff #1 received a physical exam on 7/11/12 and not again until 9/25/17. Staff #4 received a physical exam on 4/15/15 and not again until 2/22/18.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Staff physicals will be reviewed by Program Management to ensure compliance to 2380 regulations. Audits will be conducted on a quarterly schedule; any staff found to be non-compliant will be notified and given 5 days after discovery to rectify areas of non-compliance. During this time the staff will be removed from program until compliant. be an annual training. See attachment #H1-H2 06/11/2018 Implemented
2380.113(c)(2)Staff #1 had tuberculin testing completed on 7/11/12 and not again until 9/14/17. Staff #4 had tuberculin testing completed on 4/17/15 and not again until 2/22/18. Staff #6 was hired on 5/15/17 and did not receive tuberculin testing to date.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.Staff physicals will be reviewed by Program Management to ensure compliance to 2380 regulations. Audits will be conducted on a quarterly schedule; any staff found to be non-compliant will be notified and given 5 days after discovery to rectify areas of non-compliance. During this time the staff will be removed from program until compliant. be an annual training. See attachment #H1-H2 06/11/2018 Implemented
2380.113(c)(3)Staff #6's 5/5/17 physical exam did not include his communicable disease status.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.Staff physicals will be reviewed by Program Management to ensure compliance to 2380 regulations. Audits will be conducted on a quarterly schedule; any staff found to be non-compliant will be notified and given 5 days after discovery to rectify areas of non-compliance. During this time the staff will be removed from program until compliant. be an annual training. See attachment #H1-H2 06/11/2018 Implemented
2380.115(1)The facility did not have an emergency medical plan.The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency.The Program Staff was trained on 6-11-18 the Updated Emergency Action Plan. Going forward the emergency medical plan will be an annual training for all program staff. See attachment #¿s G1- G3. 06/11/2018 Implemented
2380.173(1)(i)Social security numbers were not included in the records for all individuals.Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.The Program Specialists was trained on 6-11-18 to add the last four digits of the individual¿s social security number for the individuals assigned to their caseload to the General Information Sheet. See attachment # F1 and B1-B12. Going forward information will be reviewed and updated annually by Program Specialist during annual chart audits. 06/11/2018 Implemented
2380.173(1)(ii)REPEATED VIOLATION - 3/11/16. Individual #7's and Individual #11's record did not include identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The Program Specialists was trained on 6-11-18 to include identifying marks for the individuals assigned to their caseloads to the General Information Sheet. See attachment # F1 and B1 ¿ B12. Going forward information will be reviewed and updated annually by the Program Specialist during annual audits. 06/11/2018 Implemented
2380.176(a)Individual records were stored unlocked on bookshelves and filing cabinets throughout the facility.Individual records shall be kept locked when they are unattended.All Program Specialist were trained on HIPPA and the importance of keeping all individual records locked when unattended on 6-11-18. All program records were relocated to areas with locked cabinets. New cabinets with locks have been order on 6-11-18 to be placed in the program area to be used to secure individual¿s documentation. Please see attachments: See attachment D1- D2. See attachment E1- E2. 06/11/2018 Implemented
2380.177REPEATED VIOLATION - 3/11/16. Consents to release information were not completed for any individual in the program.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.A consent to release information has been completed and sent out to all the individuals that was selected during inspection. Going forward a consent to release information will be completed for everyone by 8/30/18 and completed annually. Program Specialist during annually chart audits will ensure that consent is present, signed and filed in program chart. Please see attachments: C1- C12. 06/11/2018 Implemented
2380.181(e)(1)Functional strengths, needs, and preferences were not contained in any of the eleven assessments reviewed.The assessment must include the following information: Functional strengths, needs and preferences of the individual.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include functional strengths, needs, and preferences of the individuals. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments: A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(2)REPEATED VIOLATION - 3/11/16. Individual #2's 10/11/17 assessment did not include her dislikes.The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include likes, dislikes, and interests of individual to include vocational and employment interests. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(4)Individual #1's 9/7/17 assessment did not include her supervision needs at the program or in the community.The assessment must include the following information: The individual¿s need for supervision.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include individual¿s need for supervision. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(5)Individual #3's 2/22/18 assessment, Individual #4's 4/17/18 assessment, and Individual #8's 5/8/17 assessment did not include the ability to self administer medications.The assessment must include the following information: The individual's ability to self-administer medications.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s ability to self-administer medications. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments: A1-2 &B1-B12. 06/11/2018 Implemented
2380.181(e)(9)Individual #1's 9/7/17 assessment did not include documentation of disability. This section was not completed. Individual #2's 10/11/17 assessment did not include functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s disability, including functional and medical limitations. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(10)Individual #1's 9/7/17 assessment, Individual #4's 4/17/18 assessment, Individual #10's 1/24/18 assessment, and Individual #11's 5/9/17 assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.The Program Specialists were trained on 6-11-18 regarding how to complete the assessment comprehensively ensuring it follows 2380 regulations to include individual¿s life time medical histories. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments: M1 & B1-B12. 06/11/2018 Implemented
2380.181(e)(13)(i)REPEATED VIOLATION - 3/11/16. Individual #1's 9/7/17 assessment, Individual #3's 2/22/18 assessment, Individual #4's 4/17/18 assessment, Individual #5's 11/10/17 assessment, Individual #6's 7/13/17 assessment, and Individual #10's 1/24/18 assessment did not include current health level or progress over the past year in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s disability, including functional and medical limitations. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(13)(ii)Individual #2's 10/11/17 assessment, Individual #3's 2/22/18 assessment, and Individual #6's 7/13/17 assessment did not include current level or progress over the year in 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.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s disability, including functional and medical limitations. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(13)(iii)Individual #2's 10/11/17 assessment, Individual #3's 2/22/18 assessment, Individual #5's 11/10/17 assessment, Individual #6's 7/13/17 assessment, and Individual #10's 1/24/18 assessment did not include progress over the past year in 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.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s disability, including functional and medical limitations. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(13)(iv)Individual #2's 10/11/17 assessment, Individual #3's 2/22/18 assessment, and Individual #4's 4/17/18 assessment did not include current socialization skills or progress made over the past year.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s disability, including functional and medical limitations. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(13)(v)Individual #2's 10/11/17 assessment, Individual #3's 2/22/18 assessment, and Individual #8's 5/8/17 assessment, and Individual #10's 1/24/18 assessment did not include current recreation skills or progress made over the past year.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s disability, including functional and medical limitations. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(e)(13)(vi)Individual #2's 10/11/17 assessment, Individual #3's 2/22/18 assessment, and Individual #4's 4/17/18 assessment did not include current level of community integration or progress made over the year.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The Program Specialists was trained on how to complete the assessment comprehensively ensuring it is in compliance with 2380 regulations to include the individual¿s disability, including functional and medical limitations. Program Specialists was given a copy of 2380 regulations and this training will occur annually. Program Specialists will audit assessments quarterly to ensure compliance. See attachments A1-2 & B1-B12. 06/11/2018 Implemented
2380.181(f)All individual assessments reviewed were not sent to plan team members.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The Program Specialists were trained on how important it is to have all team members involved in the development of outcomes/ goals and the updating of the annual assessment. Therefore, all the individuals selected during inspection have had their assessments sent out to their team members via email or certified mail. Going the Program Specialist will send out assessments to the team members 90 days before the annual due date via email or certified mail. See attachment: B1-B12. 06/11/2018 Implemented
SIN-00091846 Unannounced Monitoring 03/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16On 3/16/2016 Staff #1 and Staff #2 were responsible for transporting Individual #1 and housemates to their respective day programs. Staff #2 escorted the individuals on the van to their classrooms within the day program. Individual #1 remained on the van with Staff #1. Staff #1 parked the van and entered the day program. At approximately 2:00PM, Individual # 1 was found by Staff #2 in a van parked at the Allegheny Valley School Philadelphia Program Center's parking lot. Individual #1 was left unattended on a van from approximately 9:00AM to 2:00PM. According to the AVS physician's report dated 03/16/2016, Individual #1 appeared tremulous, hair and shirt were soaked with sweat,eyes were diffusely reddened and diaper was saturated. This applies to abuse occurring at the facility. Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse. Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview On 3/17/2016, the Philadelphia Program Center Arrival Protocol was put in place. When individuals arrive to the day program their mode of transportation will be physically checked to ensure everyone has exited safely. Each individual will be escorted to their assigned classroom and their arrival time will be documented. Once the transportation process has been completed, assigned staff will go to each program area and get the names of the individuals who are marked absent. This assigned staff will get verification from their residence of the absence. [Quality Manager or Program Designee will complete monthly audits of the Arrival Protocol to ensure compliance and timely completion DD 5.13.16]Please see attached protocol. Retraining was conducted on the following topics: attendance records, vehicle checks, client safety and arrival protocol process. These training were conducted with both Day Program and Residential settings. Please see attached training documentations. 03/17/2016 Implemented
SIN-00086207 Renewal 03/10/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(c)(2)Staff # 2's qualifications to be a program specialist was not available to be reviewed.A program specialist shall have one of the following groups of qualifications:(2)  A bachelor¿s degree from an accredited college or university and 2 years of work experience working directly with persons with disabilities.On 3/17/2016, staff #2 submitted their college degree as prove of having the qualifications for their position. Please see attachment #13 for validation. Going forward the Program Coordination will complete an audit of 20 percent of the HR files every six months The audit will ensure that each staff person has qualification needed n order perform their responsibilities the positions they occupy. If there are any missing information the staff will be instructed to provide the Program Director with the needed material within 3 business days of discovery. 03/17/2016 Implemented
2380.36(a)Staff # 1 completed 23.75 hours of human services during the training year of 02/01/2015-01/31/2016.The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.Going forward the Program Coordination will complete an audit of 20 percent of the training files quarterly. The audit will ensure that each staff person has at least six hours of training relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. Any staff that have not met the six hours of training for that quarter be given training materials within 48 hours of discovery to ensure they are in compliance 03/17/2016 Implemented
2380.53(b)There were three unidentified liquids found in a spray bottle in a cabinet in Sub 2 program area.Poisonous materials shall be stored in their original, labeled containers.On 3/11/2016 the three bottles were removed from Sub 2 program area. On 3/17/2016 all program staff was trained on how to handle poisonous materials, ensuring that they remain in their original, labeled containers. Please see attachment #10 as supporting documentation of training. Going forward #A8 will be used weekly and submitted to the Program Coordinator once completed. The Program Coordinator will review all of the audits. Audits were completed on all of the 15 program areas any no other poisonous materials were found. The Program Coordinator will ensure that all poisonous materials are stored in a locked closet and remain in their original labeled container. 03/11/2016 Implemented
2380.53(c)Thick It was found stored with three Purell sanitizing wipes which indicated to contact poison control if ingested, in the DT-6 program area. Purell Sanitizing wipes, heavy duty cleaner, light duty cleaner which indicated to contact poisons control if ingested was found stored with Thick It in the DT-9 program area. Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.On 3/11/2016 areas were assigned in which to store the entire Thick it products. These areas are to be used for the storing of Thick it only. Program staff was retrained on the proper way to store all food products. Please see attachment: A#11 training documentation for validation. Going forward #A8 will be used weekly and submitted to the Program Coordinator once completed. The Program Coordinator will review all of the audits and be responsible for removing any materials that don¿t belong upon discovery. 03/11/2016 Implemented
2380.55(a)A black substance consistent with mold was accumulating under the kitchen sink in the DT-7 program area. A strong odor and stains consistent with feces was found in the shower stall in "long hallway" bathroom Clean and sanitary conditions shall be maintained in the facility.On 3/11/2016, the area was cleaned and substance was removed. On 3/11/2016 the shower stall was cleaned and odor free. On 3/17/2016 training was conducted on Physical Site Inspection Tool. Please see attachment: #A8 and #A9 for validation. Going forward #A8 will be used weekly and submitted to the Program Coordinator once completed. The Program Coordinator will review all of the audits and place request for repair through our maintenance department to get corrected. The Program Director will have the entire program area inspected on a quarterly base to ensure all repairs request have been satisfied 03/11/2016 Implemented
2380.58(b)Rust was found on the handrails located outside the emergency exit door in the DT-7 program area. Rust was found on the handrail located outside the exit door in the TA-10 program area. The wall mount telephone jack was found hanging from the wall with exposed wires in the DT-9 program area. Floors, walls, ceilings and other surfaces shall be free of hazards.On 3/11/2016 both of these handrails were repaired and painted. On 03/10/2016, The wall mount telephone jack was properly secured. On 3/17/2016 training was conducted on Physical Site Inspection Tool. Please see attachment: #A8 and #A9 for validation. Going forward #A8 will be used weekly and submitted to the Program Coordinator once completed. The Program Coordinator will review all of the audits and place request for repair through our maintenance department to get corrected. The Program Director will have the entire program area inspected on a quarterly base to ensure all repairs request have been satisfied 03/11/2016 Implemented
2380.67(a)A red chair with fabric peeling on the seat was found in the Sub 3 program area. A vinyl chair with a torn seat was found in the DT-4 program area. A red chair with a torn cover was found in the DT-9 program area. Furniture and equipment shall be nonhazardous, clean and sturdy.On 3/17/2016 both chairs where discarded. On 3/17/2016 training was conducted on Physical Site Inspection Tool. Please see attachment: #A8 and #A9 for validation. Going forward #A8 will be used weekly and submitted to the Program Coordinator once completed. The Program Coordinator will review all of the audits and place request for repair through our maintenance department to get corrected. The Program Director will have the entire program area inspected on a quarterly base to ensure all repairs request have been satisfied. 03/17/2016 Implemented
2380.69(e)A broken toilet dispenser that did not have toilet paper was found in the lower level men's bathroom. Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.On 3/17/2016 training was conducted on Physical Site Inspection Tool. Please see attachment: #A8 and #A9 for validation. Going forward #A8 will be used weekly and submitted to the Program Coordinator once completed. The Program Coordinator will review all of the audits and place request for repair through our maintenance department to get corrected. The Program Director will have the entire program area inspected on a quarterly base to ensure all repairs request have been satisfied. 03/17/2016 Implemented
2380.113(a)Staff # 3's previous physical examination was dated 08/15/2012 and the most recent physical examination was dated 04/09/2015.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Going forward the Program Coordination will complete an audit of 20 percent of the physical forms submitted by the staff. The audit will ensure that each staff person has an initial physical and one every 2 year thereafter. All staff with anniversary dates approaching will be notified in writing to submit an updated physical. Update and completed physical forms will be review for accuracy to ensure they are in compliance of the 2380 regulations. Copies of the physical forms will be maintained in their Personal Files. 04/13/2016 Implemented
2380.124aIndividual #2 is prescribed Ibuprofen 200mg PRN and it was not documented on the MAR.The medication log must identify the prescribing certified registered nurse practitioner (CRNP) when a medication was prescribed by a CRNP as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners).The 200mgs of Ibuprofen PRN was discontinued for individual #2 on 4/13/2016. Nursing Coordinator will provide trainings for all the nurses assigned to the day program by 4/30/2016 on medication admission and documentation. The nursing department will review all PRN medications and MAR's to ensure they are correct for the assigned individual on a monthly basis. 04/13/2016 Implemented
2380.173(1)(ii)Individual #7 and # 8's record did not include identifying marks. Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.On 3/15/2016 all Program Specialist were retrained on the completion of the General information sheet and the importance of ensuring that all sections have been completed. Please see attached training sheet for validation Attachment #A5. The General Information Sheet for both #7 and #8 has been updated to reflect their identifying marks. An audit of 40 charts was conducted and 3 were found to be missing the same information. All were corrected at the time of discovery. Going forward the Audit tool will be used every six months to ensure that all areas of the form are completed. Attachment #A3 will be the audit tool by the Program Specialist and Program Coordinator. 04/13/2016 Implemented
2380.173(1)(iv)Individual # 8's record did not include religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.On 3/15/2016 all Program Specialist were retrained on the completion of the General information sheet and the importance of ensuring that all sections have been completed. Please see attached training sheet for validation Attachment #A5. The General Information Sheet for both #7 and #8 has been updated to reflect their religious affiliation. An audit of 40 charts was conducted and any records found to be missing the same information were corrected at the time of discovery. Going forward the Audit tool will be used every six months to ensure that all areas of the form are completed. Attachment #A3 will be the audit tool by the Program Specialist and Program Coordinator. On 4/13/2016 individual #8¿s General Information Sheet was updated to reflect their religious affiliation. Please see attachment # 7 for validation. 04/13/2016 Implemented
2380.177Individual # 1's record did not include a consent for release of information form.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.On 4/13/2016 Individual #3 signed and dated the consent for taking pictures. Please see attachment #A4 for validation. Going forward attachment #A3 will be used as a part of the audit process to review and ensure all consents are signed, dated and present in each program file. The audit tool will be used by the Program Specialist every six months to ensure that all consent forms are within compliance. All discrepancy found during the audit process will be address and corrected within 48 hours of discovery. 04/11/2016 Implemented
2380.181(a)Individual # 5's date of admission was 01/05/2016 and the assessment was completed on 04/09/2015 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.The processing of all new admission will be tracked using the attached New Admission Audit Tool that lists required task and due dates in order to maintain compliance. The Program Coordinator inserts the admission date and all other due dates which will be completed by Program Specialist. Upon completion the Program Specialist will submit the completed audit tool and supporting documents to the Program Coordinator for final review and filing. Please refer to attachment #A1 05/01/2016 Implemented
2380.181(d)Individual # 4's annual assessment dated 06/30/2015 was not signed and dated by the program specialist. The program specialist shall sign and date the assessment.Individual #4 Assessment was signed and dated by the Program Specialist on 4/11/16. Please see attachment #A2 for validation. On 3/15/2016 the Program Specialist were retrained on the Annual Assessment and the importance of addressing each section of the document. Please see attachment: #A6. Going forward all areas of the assessment will be completed by the Program Specialist two weeks before the anniversary date. After completion the Program Specialist will submit the completed assessment to Program Coordinator within two business days for review. Program Coordinator will review all areas for completion and accuracy. Attachment #A3 will be used to complete the audit process. 04/11/2016 Implemented
2380.181(e)(2)Individual #6's annual assessment dated 10/19/2015 did not document the individual's dislikesThe assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests.On 3/15/2016 the Program Specialist were retrained on the Annual Assessment and the importance of addressing each section of the document. Please see attachment: #A6. Going forward all areas of the assessment will be completed by the Program Specialist two weeks before the anniversary date. After completion the Program Specialist will submit the completed assessment to Program Coordinator within two business days for review. Program Coordinator will review all areas for completion and accuracy. Attachment #A3 will be used to complete the audit process. 03/15/2016 Implemented
2380.181(e)(13)(i)Individual # 3's annual assessment dated 07/22/2015 did not document progress and growth in the area of health. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.On 3/15/2016 the Program Specialist were retrained on the Annual Assessment and the importance of addressing each section of the document. Please see attachment: #A6. Going forward all areas of the assessment will be completed by the Program Specialist two weeks before the anniversary date. After completion the Program Specialist will submit the completed assessment to Program Coordinator within two business days for review. Program Coordinator will review all areas for completion and accuracy. Attachment #A3 will be used to complete the audit process. 03/15/2016 Implemented
2380.183(4)Individual # 2 has 1:1 supervision and the record did not include a fading plan.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.Individual #2 Behavior Support Program reviewed by the Behavior Specialist and Psychologist on 3/11/2016 and a Fade plan was developed and added to the program plan. Please refer to attachment # CD1 for validation. Going forward the Psychologist and Behavior Specialist will perform audits of (5) behavior plans weekly to ensure any plans with 1:1 supervision have appropriate fading plans included in the program plan. Please see attached audit tool #BP2 12/11/2016 Implemented
SIN-00078225 Renewal 11/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)The changing mat located in the men's bathroom DT7, has surface tears. The mat in the PT room located off TA10 has tears and holes.Clean and sanitary conditions shall be maintained in the facility.Going forward the Program Coordinator will use the licensing inspection instrument score sheet for chapter 2380 section: Physical Site as the audit tool to ensure compliance within the facility. The audit of the facilities will occur weekly and any areas of non-compliance will be addressed using our ¿Skyline¿ work order system. Any work order request made thru Skyline will be addressed within 72 hours. Documentation of all work orders will be maintained with our maintenance data base. Please see attached supporting documentation. 12/02/2014 Implemented
2380.58(b)The woman's bathroom floor located in the long hallway has a missing 2 inch square tile. The men's bathroom ceiling down the long hallway has 2 heavily stained ceiling tiles. The lower level woman's bathroom ceiling has a water stained tile. The changing area in the laundry room has a mat that is stained and it is located next to a wall with receptacles which lack child-proof covers.Floors, walls, ceilings and other surfaces shall be free of hazards.Going forward the Program Coordinator will use the licensing inspection instrument score sheet for chapter 2380 section: Physical Site as the audit tool to ensure compliance within the facility. The audit of the facilities will occur weekly and any areas of non-compliance will be addressed using our ¿Skyline¿ work order system. Any work order request made thru Skyline will be addressed within 72 hours. Documentation of all work orders will be maintained with our maintenance data base. Please refer to attached documentation. 12/02/2014 Implemented
2380.111(a)Individual # 1's physical is dated 1/23/13 and the most recent physical is dated 2/28/14.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Beginning 3/19/15 and going forward, all areas of the assessment will be completed by the Program Specialist two weeks prior to the annual due date. During this time, the Program Specialist will also complete an audit of the annual physicals. The audit will provide oversight to ensure that all sections of the physical forms are completed and meet the regulatory requirements. The Program Specialist will record any physical that is older than nine months on a running spreadsheet, and send written notification to the residential provider informing them of the physical¿s anniversary date. This notification will serve as a reminder that the physical needs to occur within the allotted time frame in order for the individual to continue attending program. 03/11/2015 Implemented
2380.111(c)(10)The physical for individual # 2, dated 11/10/14 and Individual #3, dated 9/4/14, and Individual #4, dated 6/9/14 did not include medical information pertinet to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical form was revised to ensure all areas of compliance are incorporated. Beginning 3/19/15 and going forward, all areas of the assessment will be completed by the Program Specialist two weeks prior to the annual due date. During this time, the Program Specialist will also complete an audit of the annual physicals. The audit will provide oversight to ensure that all sections of the physical forms are completed and meet the regulatory requirements. Please refer to attached supporting documentation. 06/12/2015 Implemented
2380.181(e)(9)Individual # 5's assessment dated 3/20/14 did not document the Individual's disability including functional and medical limitations.The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.On or before 3/19/15, the Program Specialist revised Individual #5¿s assessment to include the individual¿s disability (ies), functioning level and medical limitations. On or before 3/19/15, the program director/designee will review 5% of the assessments to ensure they are completed thoroughly and meet all regulatory requirements. The review will be documented on the AVS-PPC Roster form (see attached). The Program Specialist will receive a copy of the review form, and address any noted areas of concern within 14 days. Beginning 3/19/15 and going forward, all areas of the assessment will be completed by the Program Specialist two weeks prior to the annual due date. The Program Specialist will submit the completed assessment to the program director/designee for review. The program director/designee will review all areas of the assessment for completion and accuracy, within 2 business days of receiving the assessment. Any noted discrepancies will be forwarded to the Program Specialist for immediate address prior to the assessment being filed. Please see attached supporting documentation. 03/19/2015 Implemented
2380.181(e)(12)The annual assessment for Individual #1, dated 11/21/13 and Individual #5, dated 3/20/14 did not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.On or before 3/15/15, the Program Specialist revised Individual #1¿s and Individual #5¿s assessments to include the team¿s recommendations for specific areas of training, vocational programming and competitive community integrated employment. On or before 3/19/15, the program director/designee will review 5% of the assessments to ensure they are completed thoroughly and meet all regulatory requirements. The review will be documented on the AVS-PPC Roster form (see attached). The Program Specialist will receive a copy of the review form, and address any noted areas of concern within 14 days. Beginning 3/19/15 and going forward, all areas of the assessment will be completed by the Program Specialist two weeks prior to the annual due date. The Program Specialist will submit the completed assessment to the program director/designee for review. The program director/designee will review all areas of the assessment for completion and accuracy, within 2 business days of receiving the assessment. Any noted discrepancies will be forwarded to the Program Specialist for immediate address prior to the assessment being filed. Please see attached supporting documentation. 03/15/2015 Implemented
SIN-00055877 Renewal 11/06/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff A's fire safety training of 8/6/13, was not conducted by a fire safety expert. Staff B's fire safety training of 8/6/13, was not conducted by a fire safety expert. Staff C's fire safety training of 9/30/13, was not conducted by a fire safety expert. Staff D's fire safety training of 9/19/13, was not conducted by a fire safety expert. Staff E's fire safety training of 9/6/13, was not conducted by a fire safety expert. Staff F's fire safety training of 8/9/13, was not conducted by a fire safety expert. Staff G's fire safety training of 8/14/13, was not conducted by a fire safety expert (f)  Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f). Going forward NHS trainers will be trained by a certified fire safety expert annually. The trainers that have successfully participate and completed the training by a certified fire safety expert will be responsible for training all the staff that fall under chapter 2380 regulation requirement. The staff in question were each retrained on 12/23/13 in accordance with the regulation 01/31/2014 Implemented
2380.111(c)(5)Individual #1's annual physical dated 6/3/13 did not include results of positive PPD chest x-ray Each building in which the facility operates shall have a minimum of two exits leading directly to the outside.Going forward all annual physical examinations will be reviewed by the assigned nurse upon completion to ensure all areas are completed to include PPD results and all supporting documentation. The individual in question has a history of positive PPD's, but had a negetive CXR on 12/13/13. 12/27/2013 Implemented
2380.113(a)Staff F's most recent physical was completed on 12/28/10. Staff G's most recent physical was completed on 12/28/10. (a)  A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Going forward all staff working under the 2380 regulated program will have a physical within 12 months of hire and every two year thereafter. The HR department will provide notification to each employee with whose physical anniversary date approaches the 23rd months of renewal. These individuals will be provided with written notification and form to have completed and returned within the allotted time frame. Both Staff F and G had physical examinations completed on 1/2/14. 01/15/2014 Implemented
2380.113(c)(2)Staff G's most recent tuberculin screening was completed on 10/21/10. (c)  The physical examination shall include:(2)  Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. The staff in question negitive chest x-ray dated. 8/10/12, has been placed in this staff person's file. Employees working directly with clients will be required to have a Mantoux TB test done every two years. The test results will be recorded and filed within the employees HR file. All positive results will be noted and chest x-rays will be required to ensure negative active disease. The chest x-ray result will also be documented and filed with the employees HR file. The staff in question had a chest x-ray on 8/10/12 with negitive results. This document is now in the individual's phile. 01/15/2014 Implemented
2380.124(a)Staff H administered medications on 11/5/13, but did not record a full name on the Medication Administration Record. (a)  A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.Going forward all nurses administering medication or insulin will sign each medication log after the completion of the administration cycle. A nurse will be assigned to review all medication administration logs bi-weekly to ensure that the names of all whom administered medications are clearly represented on the document medication logs. Please see attached medication log for 11/5/13. 12/27/2013 Implemented
2380.173(3)Individual #2's physical examination of 7/17/13 was not in the file. Individual #2's assessment of 9/24/13 was not in the file. Each individual's record must include the following information:(3)  Physical examinations.Each individual's record must include the following information:(4)  Assessments as required under §  2380.181 (relating to assessment).Going forward the program specialist will complete bi-monthly audits of individual's files to ensure that the most updated information is reflected in their files to include but not limited to physicals and annual assessments. The audits sheets will be reviewed and tracked by management to ensure all appropriate documents have been filed within seven days of audit. 01/31/2014 Implemented
2380.181(a)Individual #3's did not have a current assessment. (a)  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.Going forward the program specialist will complete bi-monthly audits of individual's files to ensure that the most updated information is reflected in their files to include but not limited to physicals and annual assessments. The audits sheets will be reviewed and tracked by management to ensure all appropriate documents have been filed within seven days of audit. Individual # 3's assessment was completed on 12/11/13. 01/31/2014 Implemented
2380.181(d)Individual #4's assessment dated 6/7/13, was not signed by the Program Specialist. Individual #5's assessment dated 6/24/13, was not signed by the Program Specialist. Individual #6's assessment dated 4/17/13, was not signed by the Program Specialist. (d)  The program specialist shall sign and date the assessment.Going forward the program specialist will complete all assessments two weeks before due date and submit to management. Management will review all assessments within two business days to ensure all areas have been completed, signed and reflects the individual represented. Before the assessments in placed in the individual's file all signatures from team members will be attached to the original document. The assessments were signed by the PS on 1/10/14 01/31/2014 Implemented
2380.181(e)(4)The assessments for Individual #7, dated 2/26/13 and Individual #8, dated 2/5/13 did not identify supervision needs. (e)  The assessment must include the following information: (4)  The individual's need for supervision.Going forward the program specialist will complete all assessments two weeks before due date and submit to management. Management will review all assessments within two business days to ensure all areas have been completed, signed and reflects the level of supervision needed to meet the individual level of care. The assessments for Individual #7 and Individual #8 have been updated. Please see attached sample assessment tool that addresses supervision levels. 01/31/2014 Implemented
2380.181(e)(5)The assessments for Individual #7, dated 2/26/13 and Individual #8, dated 2/5/13, did not assess their ability to self-medicate (e)  The assessment must include the following information: (5)  The individual's ability to self-administer medications.Going forward the program specialist will complete all assessments two weeks before due date and submit to management. Management will review all assessments within two business days to ensure all areas have been completed, signed and reflects the individual ability to self-administer medications. Please see attached sample assessment tool that addresses ability to self-administer medications. Individual #7 and # 8's assessments have been updated. 01/31/2014 Implemented
2380.181(e)(9)The assessments for Individual #7, dated 2/26/13 and Individual #8, dated 2/5/13, did not include their disabilities functional and medical limitations. (e)  The assessment must include the following information: (9)  Documentation of the individual's disability, including functional and medical limitations.Going forward the program specialist will complete all assessments two weeks before due date and submit to management. Management will review all assessments within two business days to ensure all areas have been completed, signed and reflects the individual disability and functional medical limitations. Please see attached sample assessment tool that addresses disabilities, functional and medical limitations. The assessments for Individual #7 and Indvidual # 8 have been updated. 01/31/2014 Implemented
2380.181(e)(12)Individual# 4's assessment dated 6/7/13 did not include a section on recommendations as required. Individual#7's assessment dated 2/26/13 did not include a section on recommendations as required. Individual#8's assessment dated 2/5/13, did not include a section on recommendations as required. Individual# 9's assessment dated 10/8/13, did not include a section on recommendations as required. Individual#10's assessment dated 8/21/13, did not include a section on recommendations as required. Individual# 11's assessment dated 7/15/13, did not include a section on recommendations as required. (e)  The assessment must include the following information: (12)  Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Going forward the program specialist will complete all assessments two weeks before due date and submit to management. Management will review all assessments within two business days to ensure all areas have been completed, signed and recommendations for areas surrounding vocational programming and competitive community integrated employment. Please see attached sample assessment tool that addresses vocational programming and competitive community employment. Individual #4's assessment has been updated. 01/31/2014 Implemented