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55 Pa. Code Chapter 2380 – Adult Training Facilities Inspection RecordA. Site Information Legal Entity Name:Service Location Name: Service Location Address: Service Location County:Licensed Capacity:Bathrooms: Sinks:Toilets:B. Inspection Information Application Number:Inspection Begin Date:SIN Number:Inspection End Date: PCID (13 Digits):Notice: Choose an item.Reason for Inspection: Choose an item.Type of Inspection: Choose an item.Inspectors: C. Participant Demographics Program ServedNumberAdult Autism Waiver:Yes?No?Adult Community Autism Program Yes?No?Community Living Waiver Yes?No?Consolidated Waiver:Yes?No?P/FDS Waiver Yes?No?Base Funded: Yes?No?Not Funded by ODP: Yes?No?Total Served (Census): NAD. Entrance Conference Start Time:End Time: Provider Representatives Present: Inspection team introduced:Yes?No?Notes:Purpose of inspection stated:Yes?No?Notes:Overview of inspection process provided:Yes?No?Notes:Provider given opportunity to ask questions about inspection or process Yes?No?Notes:General Entrance Conference Notes: E. Exit Conference Start Time:End Time: Provider Representatives Present: Preliminary violations presented:Yes?No?Notes:Provider given opportunity to ask questions about findings: Yes?No?Notes:Technical assistance provided:Yes?No?Notes:Next steps in process explained: Yes?No?Notes:Guidance for acceptable plan of correction provided:Yes?No?Notes:General Exit Conference Notes: General Requirements ??CVNANM??CVNANM11Chapter 20????17j5Responsible Person????13Capacity????17j6Date of Implementation????14aOccupancy Permit????18a1Potential Risks????14bPermit Withdrawn????18a2Health Care Info.????14cRenovations Approval????18a3Med History/Current Meds????15Wage & Hour Cert.????18a4Behavioral Health History????16Abuse????18a5Incident History????17aReportable Incident - 24 hour????18a6Social Needs????17b1Reportable Incident- 72 hours Restraint????18a7Environmental Needs????17b2Reportable Incident- 72 hours Medication error????18a8Personal Safety????17c24-hour Notification????18bCorrective Plan Implemented????17dNotification Kept????18cPlan Revised, if Indicated????17eFinal Report Available????19a1Confirmed Incident – Analysis of Cause????17fImmediate Action????19a2Corrective Action????17gInvestigation – 24 Hours????19a3Potential Risk Strategies????17h1CI investigate: Death????19b3-month review/analysis????17h2Inpatient????19c1Preventative Measures: Reduce incidents?? ??17h3Abuse????19c2Severity of Risk????17h4Neglect????19c3Likelihood of Recurrence????17h5Exploitation????19dEducate Staff????17h6Injury: Treatment beyond first aid????19eMitigate/Manage Risks????17h7Theft/Misuse of Funds????20aPSP w/in 5 days????17h8Rights Violation????20bFBI w/in 5 days????17iFinal Report – 30 days????20c1 yr. prior to DOH????17j1Content of Report – Additional Info????20dCopy of Final Reports Kept????17j2Results of Investigation????22Grievance Procedures ????17j3Action Taken????26Other Statutes/Ordinances????17j4Corrective Action????ments Individual Rights CVNANMCVNANM21aDeprived of Rights????21lMake Choices/Accept Risks????21bAccommodations????21mRefusal of Activities????21cExercise Rights - Punishment????21nPrivacy of Person/Possessions????21dCourt Order Followed????21oAccess/Security of Possessions????21eLegal Guardian – Rights/Decisions????21pVoice Concerns????21fIndividual Involved with Decision making????21qParticipate in Plan Development????21gDesignated Person????21rViolation of Others’ Rights????21hDiscrimination????21sResolve Differences????21iCivil/Legal Rights????21tRights Modified????21jAbuse, Neglect, Mistreatment????21uIndividual Informed????21kDignity and Respect????21vSigned Statement????ments StaffingCVNANMCVNANM32aCEO????37b Record Per Person????32b1CEO – Implement Policies????38a1Orientation: Mngmt/Admin/Prgrm/Fisc????32b2CEO – Admn/Discharge of Ind.????38a2Diet/Housekeep/Maint????32b3CEO -Safety & Protect. of Ind.????38a3Full/Part time DSP????32b4CEO - Compliance????38a4Volunteers????32c1CEO – Master’s + 2 Yrs.????38a5Paid/Unpaid Interns????32c2CEO – Bachelor’s + 4 Yrs.????38a6Consultants????33aP. S. 30 Ind.????38b1Orientation includes: Person Centered Practices, Community Integration, etc????33b1P.S. Coordinate/Complete Assessments????38b2Prevention, Detection, Reporting of Abuse????33b2P.S. Participate in Plan Process ????38b3Individual Rights????33b3P.S. Provide/Supervise Activities????38b4Recognize/Report Incidents????33b4P.S. CommunityIntegration????38b5Job-related skills/knowl????33b5P.S. Family/Friend Involvement????39a1Annual Training - 24 Hrs: DSW????33c1PS Qualifications: Masters + 1-year experience????39a2Direct Sup(s) of DSW’s????33c2P.S. Bachelors + 2-year ????39a3Other Required Positions????33c3P.S. Associates/60 credits + 4 years ????39b1Training -12 Hrs: Mngmt/Admin/Prgrm/Fisc-????34Direct Services Worker????39b2Diet/Housekeep/Maint????35a1 to 6 Ratio????39b3Consultants????35b1 to 10 During Meetings????39b4Volunteers????35cMin. 2 Staff At All Times????39b5Paid/Unpaid Interns????35dUnsupervised if specif. in Assessment/ISP????39c1Content: Person Centered Practices, Community Integration, etc????35eStaff Qual. & ratios implemented as written????39c2Prevention, Detection, Reporting of Abuse????35fUnsupervised for Convenience????39c3Individual Rights????36aGeneral Fire Safety – before working w/individuals????39c4Recognize/Report Incidents? ???36bPS/DSPW Fire Safety Annually by expert????39c5Use of Behavior Supp????36c1:18 – Min 2 Staff at all times – First Aid/CPR training????39c6Plan Implementation????37aTraining Records Kept????ments Physical SiteCVNANMCVNANM51Special Accommodations????63aScreens when Opened????52a50 Sq. Ft. per Ind.????63bGood Repair????52bEach Separate Room????64aHandrail; More Than 2 Steps????53aPoisons Locked????64bPorch Railing????53bPoisons; Original Contain. Label????65Nonskid Surfaces????53cPoisons Separate from Food????66aStairway Landing????54Heat Sources????66bLanding as wide as Stairs????55aClean & Sanitary????66c3ft Landing????55bInfestation/Rodents????67aFurniture; Clean, Safe, Sturdy????55cTrash Removed Weekly????67bFurniture & Equip. App.????55dIndoor Trash Covered, Cleanable????68Storage Space????55eOutdoor Trash Covered????69a1:18 toilets????55fSewage Approval????69b1:24 sinks????55gSewage Checked 4yrs.????69cHandicap Accessible????56Ventilation????69dSeparate Bathrooms if >18????57Lighting????69eBathroom Contents????58aSurfaces in good repair????69fBathroom Privacy????58bSurfaces free of hazards????70aPrivate First Aid Area????58cLead Paint Testing????70bFirst Aid Area Contents????59aWater Under Pressure????70cFirst Aid Kit Each Floor????59bHot Water - 120°????70dFirst Aid Kit Contents ????59cColiform Test every 3 months????70eFirst Aid Manual????60aIndoor Temp 65°????71Elevator Approval????60bFans above 85°????72aOutside Walkways????61Telephone????72bOutside Conditions????62Emergency Phone Numbers????ments Fire Safety CVNANMCVNANM81Exits????88fExtinguishers Inspected Annually????82Unobstructed Egress????89aMonthly unannounced Fire Drills????83aEmergency Evacuation Policy????89bNormal Staffing Conditions????83bDiagram in Facility????89cWritten Fire Drill Records????84Annual Fire Safety Inspection????89dWithin 2 ? Minutes????85Flammable Materials????89eAlternate Routes????86Portable Space Heaters????89fAlternate Times/Days????87aOperable Fire Alarms????89gDesignated Meeting Place????87bAccommodations to Alarms????89hAlarms Set Off????87cInoperative Alarms Repairs????90aExit Signs????87dInoperable Alarms Policy????90bDirection Signs????88a1 2-A Fire Extinguisher per????91aFire Safety Training for Individuals????88b5,000 sq. ft. 2-A Extinguishers????91bDoc. of Inability to Train????88c10-B Extinguisher in Kitchens????91cRecord of Training????88dFire Extinguishers Approved????92aSmoking Safety Procedures????88eFire Extinguishers Accessible????92bProcedures Followed????ments Individual/Staff Health CVNANMCVNANM111aPhys. Exam w/in 12 mo. & Annual????112Doc. Refusals????111bSigned & Dated????113aStaff Phys. w/in 12 mo. & 2yrs????111c1Previous Medical History????113bSigned & Dated????111c2General Physical Exam????113c1General Physical Exam????111c3Immunizations????113c2TB Test & Results – every 2yrs????111c4Vision & Hearing Screenings????113c3Communicable Disease Statement????111c5TB Test & Results – every 2yrs????113c4Med Probs. that May Interfere????111c6Comm. Disease Prescription????114aCommunicable Disease Auth.????111c7Health Maintain Blood Work, Meds????114bStatement????111c8Physical Limitations????114cPrecautions Followed????111c9Allergy./Contradicting Med.????115(1)Emergency Plan – hospital????111c10Info in case of Emergency????115(2)Emergency Plan – transport????111c11Special Diet Instructions????115(3)Emergency Plan – emergency staffing plan ????111dRN/LPN Signature Exceptions????ments Medications CVNANMCVNANM121aSelf-Admin: Assistance????126a5Strength of Med????121bTypes of Assistance????126a6Dosage Form????121cAssistive Technology????126a7Dose of Med????121dSelf-Admin Status in Plan????126a8Route of Administration????121e1SA: recognize meds????126a9Frequency of Admin????121e2SA: How much ????126a10Administration Times????121e3SA: When to take????126a11Diagnosis/Purpose????121e4SA: Assistive Tech.????126a12Date/Time of Admin????122aAdmin by Qualified Staff????126a13Name/Initials of Person Administering????122b1Qualified Staff ????126a14Duration of Treatment, If applicable.????122b2Med Trained Staff - Admin????126a15Special Precautions, If Applicable.????122c1Med Admin: Identify Indiv????126a16Side Effects, if Applicable????122c2Remove from orig. cont. ????126bLogged Immediately ????122c3Prepare Med as Ordered????126cRefusal Documented on Log????122c4Med in Med Cup/Cont.????126dDirections Followed????122c5Vital Signs, if indicated????127a1Med Errors: Failure to administer Med????122c6Injection of insulin/epineph????127a2Wrong Med Admin????123aOriginal Labeled Container????127a3Wrong Dose Admin????123bRemoval from Container????127a4Failure to Admin at Pres. Time????123cInsulin/Epinephrine not individual dose container????127a5Administered -Wrong Person????123dMeds/Syringes Locked????127a6Wrong Route????123eEpinephrine Stored Safe/Accessible????127a7Wrong Position????123fRefrig. Meds – Locked Container????127a8Improper preparation????123gStorage of Meds????127bDoc. of Med Errors????123hDisposal of Meds????127cError Reported as in 17b????123iN/A self-admin individuals????127d1Reported to prescriber: Not Admin as directed????125aAuthorized Prescriber????127d2Admin to Wrong person????125bCurrent Order????127d3Harm to Individual????125cAdministered as Prescribed????128aAdv Reaction- Consult Dr.????125dUse of Meds????128bResponse/Action Documented????125eWritten Changes????129aMed Admin Training????125fSEEN Protocol in Plan????129b1Insulin Admin: Med Admin Course????126a1Med Log: Individual Name????129b2Training by Health Care Professional: 12 Months????126a2Prescriber????129c1Epinephrine Admin: Med Course????126a3Drug Allergies????129c2Training by Health Care Professional- 24 Months????126a4Medication Name????129dTraining Record Kept????ments Nutrition CVNANMCVNANM131aDining Area????132(7)Food – Quantity????131bDining Area-Clean & Sanitary????132(8)Ind. – Prescription Diet Followed????131cDining Area-Tables & Chairs????132(9)Food-Storage/Proper Temperature????132(1)Menus – Posted/Visible????132(10)Food-Protected????132(2)Menus-Posted 1day Prior????132(11)Food Returned????132(3)Menus – Followed????132(12)Utensils-Properly Cleaned????132(4)Menus – Retained/2 Mos.????132(13)Dishwasher Temp./San.????132(5)Food-4 Hours/Meal, 6 Hours/Snack????132(14)Dishwasher- Operation????132(6)Food –4 Food Groups????ments Restrictive Procedures CVNANMCVNANM151Definition????166(3)Pressure Point Tech.????152Policy????166(4)Chemical Restraint????153aRetribution, Convenience????166(5)Mechanical Restraint????153b1Anticipate, De- Escalate????167cPhys. Restraint - Prone Position????153b2Less Restrictive Technique????167dPhys Rest – Pain, Hyperextension, Humiliation????154aReview Committee????169aFunds/Property as Reward/Punishment????154bCommittee Includes BSP????Permitted Procedures154cMajority Not Providing Services????166(3)Clinically Accepted Bite Release????154dRecord of Meetings kept????166(4)Prescribed Drug????156aEthics/ Use of RP- 12 mos.????166(5)Prescribed Device????156bSpecific RPs used????167aPhys. Rest Emergency????156cExperienced Use of RP????167bEscort/Guide/Redirect/Physical Prompts????156dDoc. Of Training????167fPhys Rest: 30min/2Hrs????Prohibited Procedures169b1Personal Funds - Consent for Restitution ????166(1)Seclusion????169b2Consent obtained w/ indiv or designee????166(2)Aversive Conditioning????169b3Coercion prohibited????ments Individual Records CVNANMCVNANM171aEmergency Information at facility ????173(1)iiiMeans of Communication????171b1Info. – Emergency Contact Person????173(1)ivReligious Affiliation????171b2Info. – Source of Health????173(1)vCurrent, dated Photograph????171b3Info. – Consent Person????173(2)Incident Reports????171b4Info. – Physical Exam????173(3)Physical Examinations????172aSeparate Individual Record????173(4)Assessments????172bRecord Entries????173(5)Individual Plan Docs.????173(1)iName, sex, DOA, DOB, SSN????173(6)Psych Eval.????173(1)iiRace/ht/wt/hair/eye/mark????ments Record LocationCVNANMCVNANM174aRecords Kept at Facility????175bInd. Record – 4Yrs./Depart????174bRecent Copies Kept at Fac.????176aInf. Records Locked????174cNot Current Copies- Facility????176bAccess to Records????175aRecord Info.- 4 Yrs.????177Consent for Info. Release????ments AssessmentCVNANMCVNANM181aInitial/Annual Assessment????181e9Functional/Med. Limits ????181bAssess/Service Revised????181e10Lifetime Med History ????181cBasis of Assessment????181e11Psychological Evaluation ????181dP.S. Sign & Date????181e12Recommendations ????181e1Strengths, Needs, & Preferences????181e13i Progress - Health????181e2Likes, Dislikes, & Interests????181e13ii Motor/Communication ????181e3iFunctional Skills????181e13iii Daily Living ????181e3iiCommunication????181e13iv Personal Adjustment????181e3iiiPersonal Adjustment????181e13v Socialization ????181e3ivNeeds w/ or w/o Assistance????181e13vi Recreation????181e4Need for Supervision????181e13vii Financial Independence????181e5Ability to Self-Admin Meds????181e13viii Manage Personal Property????181e6Ability to Avoid Poisons????181e13ixCommunity Integration????181e7Knowledge of Heat Sources????181e14Water/Swim Safety? ???181e8Ability to Evacuate????181fCopy to SC/Plan Team????ments Plan Development/Process/ContentCVNANMCVNANM182aPS Coordinate Plan????185(1)Plan: strengths/abilities/needs????182bDeveloped w/in 90 days????185(2)Individual Preferences????182cInitial Develop, Revised Annually/Needs Change????185(3)Desired Outcomes????182dIndividual/Designees Involved????185(4)Services to Assist Achievement of Outcomes????183a1Plan Team Includes: Indiv????185(5)Risks to health/safetyRisk Mitigation Strategies????183a2Designated Persons????185(6)Modification of rights????183a3Direct Care Staff????186Plan Implemented????183a4Program Specialist????155aBSP/RPP in Plan -Approved by Human Rights Team ????183a5Residential PS – If Applic.????155bHuman rights Team Review – 6 months ????183a6Other Specialists????155c1Specific Behaviors ????183b3 Members + Indiv Present????155c2Assessment of Behavior????183cParticipant List Kept????155c3Desired Outcome????184(1)Plan Process: Individual Directs Plan Process????155c4Target Date?? ??184(2)Make Choices/Decisions????155c5Methods for Facilitating Positive Behaviors????184(3)Important to Individual????155c6Restrictions and Circumstance for use ????184(4)Occur Timely????155c7Amount of Time ????184(5)Understandable Language????155c8Staff Person Responsible ????184(6)Cultural Considerations????155dBSP Developed by Certified BS if modifying rights????184(7)Guideline: Solving Disagreements????168Emergency Basis????184(8)Method to request updates????ments Facility Services CVNANMCVNANM188aProvide Services????188cServ. Specified in ISP????188bParticipate in Community Life????188dAge/Functionally Approp.????ments Privacy Coding Document (Last Page – No other content permitted)Staff#Staff Name Title Individuals #Individual Name ................
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