| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(e) | Staff # 2's New Employee Orientation documentation does not include evidence that she was trained in notification of the local fire department as soon as possible after a fire is discovered. | Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities 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. | On 3/6/20 the Operations Manager conducted training with employee #2 regarding how to notify the local fire department as soon as possible after a fire is discovered.
On 2/20/20 the orientation outline was revised to include specific language about notification of the local fire department as soon as possible after a fire is discovered.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of staff training files to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.36(h) | Staff # 1's 07/16/19 training on Individual and Behavioral Emergencies lists the length of the training as 0.0 hours. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | On or before 4/15/20, the Operations Manager will conducted training with employee #1 in Individual Behavioral Emergencies.
On or before 4/15/20, Human Resources will correct the number of hours on the signature sheet for the Individual and Behavioral Emergencies.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of staff training files to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.89(a) | No fire drills were held January 2019, February 2019, March 2019 or April 2019. Note: January, February, and April there is documentations of Pull Station Testing from the fire alarm company. | An unannounced fire drill shall be held at least once a month. | Beginning May 2019 the Operation Manager maintains a digital and hard copy record of monthly fire drills. Documentation of fire drills will be maintained in CareLogic.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of fire drill documentation to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.91(a) | Individual # 1 received fire safety training on 01/17/19 and not again until 02/11/20 | 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. | On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
On or before 4/15/20, Program Specialists will prepare a listing of annual training deadlines for all clients on their caseloads and will review the list monthly to ensure CSP staff are meeting these deadlines.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers fire safety training to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.111(c)(1) | Individual # 2's 03/18/19 physical examination does not include evidence that the physician received or reviewed a copy of Individual # 2's medical history. The space was left blank on the physical.
Individual # 1's physical examination dated 11/19/19 does not indicate that the physician received or reviewed a copy of his medical history.
Individual # 3's physical examination dated 05/02/19 does not include evidence that Individual # 3's physician received or reviewed a copy of her medical history. | The physical examination shall include: A review of previous medical history. | Corrected copies of Individual #1s and Individual #3s physical forms were received by the program prior to 3/7/20. The program is working with Individual #2s guardian to obtain a corrected physical form.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
The Manager, Corporate Compliance, or their designee will conduct a 100% review of consumer physicals to determine compliance. If issues are noted, the Program Manager will be contacted to correct the issue.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers physicals to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.111(c)(4) | Individual # 1's physical examination dated 11/19/19 did not include a vision or hearing screening. Form states "did not complete". | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | A corrected copy of Individual #1s physical form, indicating no change in hearing or vision check, was received by the program prior to 3/7/20.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
The Manager, Corporate Compliance, or their designee will conduct a 100% review of consumer physicals to determine compliance. If issues are noted, the Program Manager will be contacted to correct the issue.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers physicals to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.111(c)(6) | Individual # 1's physical examination dated 11/19/19 does not include information pertaining to communicable diseases. The space was left blank on the physical.
Individual # 3's physical examination dated 05/02/19 does not provide the date of her most recent TB test. Her physical states "Fall 2018" as TB date. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals. | Corrected copies of Individual #1s and Individual #3s physical forms, including TB test results, were received by the program prior to 3/7/20.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
The Manager, Corporate Compliance, or their designee will conduct a 100% review of consumer physicals to determine compliance. If issues are noted, the Program Manager will be contacted to correct the issue.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers physicals to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.111(c)(10) | Individual # 2's 03/18/19 physical examination does not include information pertinent to diagnosis in case of an emergency. The space was left blank.
Individual # 1's physical examination dated 11/19/19 does not include information pertinent to diagnosis in case of an emergency. The space was left blank on the physical.
Individual # 3's physical examination dated 05/02/19 does not include information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Corrected copies of Individual #1s and Individual #3s physical forms, including medical information pertinent to diagnosis treatment in case of an emergency, were received by the program prior to 3/7/20. The program is working with Individual #2s guardian to obtain a corrected physical form.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
The Manager, Corporate Compliance, or their designee will conduct a 100% review of consumer physicals to determine compliance. If issues are noted, the Program Manager will be contacted to correct the issue.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers physicals to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.111(c)(11) | Individual # 2's 03/18/19 physical examination does not include special diet instructions. The physical form does not include space for special diet instructions to be reviewed and responded to.
Individual # 1's physical examination dated 11/19/19 does not include special diet instructions. The physical form does not include space for special diet instructions to be reviewed and responded to.
Individual # 3's physical examination dated 05/02/19 does not include special diet instructions. The physical form does not include space for special diet instructions to be reviewed and responded to. | The physical examination shall include: Special instructions for an individual's diet. | Corrected copies of Individual #1s and Individual #3s physical forms, including special diet instructions, were received by the program prior to 3/7/20. The program is working with Individual #2s guardian to obtain a corrected physical form.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
The Manager, Corporate Compliance, or their designee will conduct a 100% review of consumer physicals to determine compliance. If issues are noted, the Program Manager will be contacted to correct the issue.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers physicals to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.171(b)(3) | Individual # 2's face sheet and emergency medical consent form do not identify his mother as the person authorized to give medical consent. Individual # 2's ISP identifies his mother as the person able to give medical consent | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | The Program Specialist will update Individual #2s and Individual #3s face sheet to include emergency contact and emergency consent contact information by 4/15/20.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers face sheets to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.173(1)(ii) | Individual # 1's face sheet does not include identifying marks.
Individual # 3's face sheet does 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 Specialist will update Individual #1s and Individual #3s face sheet to include identifying marks by 4/15/20.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers face sheets to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.173(1)(iv) | Individual # 1's face sheet does not identify his religious affiliation.
Individual # 3's face sheet does not identify her religious affiliation. | Each individuals record must include the following information: Personal information including: Religious affiliation. | The Program Specialist will update Individual #1¿s and Individual #3s face sheet to include religious affiliation by 4/15/20.
On 3/6/20 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers face sheets to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/15/2020
| Implemented |
| 2380.181(e)(3)(iii) | Individual # 4's Assessment dated 12/18/2019 states no changes. This is Individual # 4's initial assessment. An assessment of Individual # 4's personal adjustment should have been completed | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | The Program Specialist updated Individual #4¿s assessment on 2/20/20 to include to include proof of assessment of personal adjustment.
On 3/6/20 training was conducted by the Operations Manager for Program Specialist and Community Support Professional staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.181(e)(4) | Individual # 4's current assessment 12/18/2019 only states he can have 15 min without supervision when he is at day program. This statement is not clear. Also, this section of his assessment should include Individual # 4's abilities and supervision needs in other environments and applicable situations. These statements concerning Individual # 4's service needs around supervision do not support what is in his current ISP states. | The assessment must include the following information: The individual¿s need for supervision. | The Program Specialist updated Individual #4s assessment on 2/20/20 to include to include his need for supervision at the day program and his needs for supervision in other environments and applicable situations.
On 3/6/20 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.181(e)(4) | Individual # 4's current ISP 12/20/2019 states line of sight at day program. Assessment states 15 minutes of unsupervised time. These statements do not give a clear, complete accurate representation of Individual # 4's abilities and service needs | The assessment must include the following information: The individual¿s need for supervision. | The Program Specialist updated Individual #4s assessment on 2/20/20 to include to include his need for supervision at the day program and his needs for supervision in other environments and applicable situations.
On 3/6/20 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.181(e)(5) | Individual # 2's assessment dated 12/16/19 does not identify his ability to self-administer medications.
Individual # 1's assessment date 11/19/19 does not identify his ability to self administer medications.
Individual # 3's assessment dated 03/25/19 does not identify her ability to self administer medications. | The assessment must include the following information: The individual¿s ability to self-administer medications. | On 2/26/20 the Operations Manager conducted an evaluation, based on information from the ISP and consumers parent, and updated Individual #2s assessment regarding Individual #2s ability to self-administer medication.
On 2/26/20 the Operations Manager conducted an evaluation, based on information from the ISP, and updated Individual #1s and Individual #3s assessments regarding the individuals ability to self-administer medication.
On 3/6/20 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.181(e)(9) | Individual # 2's assessment dated 12/16/19 does not include documentation of his disability. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | The Operations Manager updated Individual #2s assessment on 2/26/20 to include proof of functional/medical limitations & disability.
On 3/6/20 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.181(e)(10) | Individual # 2's assessment dated 12/16/19 does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The Operations Manager completed new Lifetime Medical History for Individual #2 on 2/26/2020.
On 3/6/20 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumers lifetime medical history documentation to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |
| 2380.181(f) | There is no documentation that Individual # 4 received a copy of his current 12/18/2019 assessment. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The Program Specialist updated Individual #4s assessment on 2/20/20 to include proof of assessment being sent to individual #4 by copying envelopes and e-mails.
On 3/6/20 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
04/01/2020
| Implemented |