Informational Memo. Submission of Remediation Information by Licensed Providers. ODP Communication Number: Memo

Transcription

1 Informational Memo Submission of Remediation Information by Licensed Providers ODP Communication : Memo The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives. AUDIENCE: Providers licensed in accordance with 55 Pa. Code Chapters 2380 (relating to adult training facilities), 2390 (relating to vocational facilities), 6400 (relating to community homes for individuals with intellectual disability) and Chapter 6500 (relating to family living homes). PURPOSE: This memorandum is to inform licensed providers of the new process to validate corrective actions for regulatory violations cited contained on the Licensing Inspection Summary with inspections ending July 1, 2015 and thereafter. BACKGROUND: The performance measures in the Federally-approved waivers require that, in the event of noncompliance, timely action is taken to correct violations and prevent recurrence. In accordance with the Federally approved waivers, the Office of Developmental Programs (ODP) must assure that remediation is carried out for all performance measures, for those licensed facilities funded through the Home and Community-based Waiver programs. These performance measures are identified in the quality management strategies of the Consolidated and Person/Family Directed Support (P/FDS) Waivers. The Department of Human Services, Bureau of Human Services Licensing (BHSL) is responsible for licensing management and administration. In an effort to ensure ODP can demonstrate compliance with the Centers for Medicaid and Medicare Services (CMS) assurances, the following process was developed to ensure information related to remediation is both received by BHSL and made available to ODP. DISCUSSION: Two performance measures contained in the Consolidated and Person/Family Directed Support (P/FDS) waivers rely on data collected through the licensing process. These performance measures assess compliance of the Qualified Provider (QP) CMS Waiver Assurance ISSUE DATE: 07/02/15 ODP COMMUNICATION NUMBER: Memo Page 1

2 area and the Health and Welfare (HW) CMS Waiver Assurance area. The performance measures are: 1. and percent of licensed providers that meet training requirements in accordance with state requirements (Performance Measure QP a.i.c.1 found in Appendix C). 2. and percent of licensed providers that ensure waiver participants receive physical exams in accordance with ODP rules (Performance Measure HW a.i.16 found in Appendix G). Attachment #1 and #2 contain the regulations, by chapter and section, which are assessed as part of the analysis of the above performance measures. All violations with the regulations listed in the attached document must be corrected (remediated) and validated by BHSL within 90 days from the date of the violation in order to comply with CMS expectations. Evidence that citations have been corrected or remediated must be sent to BHSL, Licensing Regional Office, via mail or fax, and include the following elements: 1. The Inspection or SIN# indicated in CLS. 2. The regulation number. 3. The names of the individual(s) and/or staff affected by the regulatory violation. 4. A copy of a document substantiating the correction such as the physical exam form or training attendance record with the date of correction. Information submitted by the provider will be reviewed by BHSL. If the information is deemed sufficient, the licensing inspection summary will be updated to reflect a corrected date and a validation date. If the information is deemed insufficient, BHSL will contact the provider and indicate why the information is not sufficient and request additional evidence. Please note, if the regulatory violation is not remediated and validated within 90 days of the date of the citation, sanctions may be applied. For questions related to this information or to submit documentation to support remediation efforts, please contact your regional BHSL licensing administrator. Central Region PO Box 2675 Room 430 Willow Oak Building Harrisburg, Pa Ph: Fax: Western Region 11 Stanwix St. Room 230 Pittsburgh, Pa Ph: Fax: Northeast Region 100 Lackawanna Ave Rm 330 Scranton State Office Building Scranton Pa Ph: Fax: Southeast Region 1001 Sterigere St. Norristown State Hospital Room 161 Building 2 Norristown, Pa Ph: Fax: ISSUE DATE: 07/02/15 Page 2

3 Regulations Pertaining to Training Requirements Chapter Section Regulation Regulation Topic Chapter Staff 46(a) Staff Orientation Community Training 46(b) Training Syllabus 46 (c ) CEO- 24 Hours Training 46(d) Staff Training 24 Hours 46(e) Training 46(f) Initial Fire Safety Training 46(g) Annual Fire Safety Training 46(h) Initial First Aid Training 46(i) First Aid, CPR, Heimlich Chapter 6500 Family Living Attachment #1 Fire Safety 113(a) Individual Trained 113(b) Documentation if No Training 113( c) Training Record Medications 168(a) Staff Training 168(b)(1) Insulin Administration- Training 168(d) Certified Trainer Restrictive 196(a) Positive Approaches Training Procedure 196(b) Specific Restrictive Procedure Training 196(d) Documentation of Training 199(j) Training for Individual to Reduce Drug in the Future 200(c)(6) Training for Individual to Reduce or Eliminate the Need for Restraint in the Future Staff 45(a) Pre-service Training Training 45(b) First Aid/ Heimlich 45( c) CPR 46(a) 24 Hours Annual Training 46(b) Family Living Staff Annual Training 47 Training Records Fire Safety 110(a) Training Plan 110(b) Training Plan Content 110 (c) Training Completed 110(d) Record of Training Medications 138(a) Training by Physician 138(b) Insulin Training 138 (c) Documentation of Training Restrictive 166(d) Documentation of Training Procedure 169(i) Training of Individual ISSUE DATE: 07/02/15 Page 3

4 Regulations Pertaining to Training Requirements Chapter Section Regulation Regulation Topic 170(c)(6) Training of Individual Chapter Adult Training Chapter Vocational Staff 36(a) Staff Orientation Training 36(b) CEO Training 24 Hours 36(c) Staff Training 24 Hours 36(d) Staff Training- Initial 36(e) Fire Safety Training- Initial 36(f) Fire Safety Training - Annual 36(g) First Aid/ Heimlich/CPR 36(h) Training Records Fire Safety 91(a) Initial Fire Safety Training 91(b) Documentation if No Training 91 (c) Training Record Medications 128(c) Training Conducted by Certified Trainer 128(d) Practicum Completed Annually 128(e) Training Documentation Restrictive 156(a) Positive Approaches Training Procedures 156(b) Specific Restrictive Procedure Training 156(d) Documentation of Training 159(j) Training For individual to Reduce or Eliminate use of Chemical Restraint 160(c)(6) Training for Individual to Reduce or Eliminate use of Mechanical Restraint Staff 40(a) Orientation for Staff Training 40(b) 24 Hours Staff Training 40(c) Records of Training Fire Safety 87 Initial Training and Annually Thereafter Training ISSUE DATE: 07/02/15 Page 4

5 Regulations Pertaining to Physical Exam Requirements Chapter Section Regulation Chapter Individual 141(a) Community Health Chapter 6500 Family Living Chapter Adult Training Chapter Vocational Regulation Topic Individual Exam within 12 months of Health 121(a) Individual Exam within 12 months of Health 111(a) Individual Exam within 12 months of Content of Records 124(5) Each client s record must include the following information: (5) Physical examinations. ISSUE DATE: 07/02/15 Page 5