| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(d) | Staff person #4 resided outside the Commonwealth of Pennsylvania directly prior to their date of hire, 11/22/22, and has direct contact with individuals. At the time of the 2/22/23 inspection, the facility did not provide an "official" copy of the final report from the FBI. The facility provided an "unofficial copy" of a federal criminal history record information (CHRI) search completed in September 2022. | A copy of the final reports received from the State Police, and the FBI, if applicable, shall be kept. | Official copy of FBI clearances requested by the HR Generalist, on 2/28/2023. Friendship Community Employment Policy shall be updated by the Associate Director of Human Resources, clarifying that only official FBI clearances shall be accepted. |
03/27/2023
| Implemented |
| 2380.173(1)(ii) | Individual #3's record does not include their identifying marks. Their face sheet states their identifying mark was that they wear glasses. However, glasses can be removed from oneself and is not an identifying marker. | 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. | Individual # 3's face sheet was updated on 2/24/23 to include identifying marks (attachment #1). Day Services Coordinator will retrain Program Specialists in regulation 2380.173(1) (ii) by 4/30/23. |
04/30/2023
| Implemented |
| 2380.174(b) | Individual #1's individual plan kept at the facility was last updated on 5/10/22. At the time of the 2/22/23 inspection, their most recent individual plan was updated on 2/21/23, and has been updated 9 times since 5/10/22.
Individual #2's individual plan kept at the facility was last updated on 5/27/22. At the time of the 2/22/23 inspection, the individual's individual plan was last updated on 1/4/23 due to the transfer of service location and needs to the new facility. Their individual plan has been updated 6 times since 5/27/22.
Individual #3's individual plan kept at the facility was last updated on 12/5/22. At the time of the 2/22/23 inspection, their most recent individual plan was updated on 1/10/23. | The most current copies of record information required in § 2380.173(2)-(11) shall be kept at the facility. | 3/9/23 most recent copies of ISPs for Individuals #1 (attachment #3 and #4), #2 (attachments #5 and #6), and # 3 (attachments #10 and #11) placed in their records. |
04/30/2023
| Implemented |
| 2380.181(e)(7) | Individual #2's current, 1/14/23 assessment does not include their ability to sense and move away quickly from heat sources. Their assessment indicates they can move away from heat sources independently and that if they were told to move away from a heat source, they would comply. However, the individual is wheelchair bound and the assessment discusses the individual's need for physical assistance occasionally. The assessment does not discuss their ability to move away quickly.
Individual #1's current, 1/11/23 assessment does not include their ability to sense and move away quickly from heat sources. Their assessment indicates they can move away from heat sources independently and that if they were told to move away from a heat source, they would comply. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Program Specialist will conduct an audit of all Individual's assessments to assure compliance with regulation 2380.181(e) (7). Addendums created for Individual #1 (attachment #7) 3/10/23 and #2 (attachment #8) 3/13/23. |
04/30/2023
| Implemented |
| 2380.36(b) | The agency did not produce records that Staff persons #1 and #2 received fire safety training specific to the new building location when they first started working with individuals in the new building on 1/9/23.
Staff person #1's and #2's most recent training on fire safety was completed on 8/12/22 and 6/30/22, respectively. The trainings were not specific to the new building location to include the new evacuation routes, designated meeting place outside the new location, smoking safety procedures, responsibilities during fire drills, and the location of the smoke detectors and fire extinguishers. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | FC Training Policy shall be updated to specify that new openings require updated fire safety training to include new evacuation routes, designated meeting place outside the new location, smoking safety procedures, responsibilities during fire drills, and the location of the smoke detectors and fire extinguishers. |
04/30/2023
| Implemented |
| 2380.37(a) | The training records for Staff persons #2 and #3 have many hours of training in single days for each staff. Staff person #2 was documented as having 30 hours of training on 2/1/22 and 22 hours of training on 7/14/22. Staff person #3 was documented as having 40 hours of training on 5/19/22. On multiple occasions, Staff persons #2 and #3 are documented as receiving more training hours than there are actual hours in the day. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | FC Training Policy shall be updated to specify that a maximum of 16 hours of training credit can be claimed per day. |
03/31/2023
| Implemented |
| 2380.39(c)(6) | Staff person #1 started working with Individual #3 since the individual's first day on 1/11/23. Staff person #1 did not review the individual's individual plan until 2/22/23. Additionally, there is no documentation that a trainer provided the training of the individual's plan to Staff person #1, but that Staff person #1 completed a reading independently and not in a training session. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Retraining shall be provided by the Associate Director of Human Resources to the Day Services Coordinator regarding the need for training on the ISP to occur for team members prior to Team Member's working with an Individual. This shall be completed by 3/31/23 and documentation of retraining shall be kept on file. |
03/31/2023
| Implemented |
| 2380.125(f) | Individual #2 takes psychotropic medications for a psychiatric diagnosis. Their individual plan does not contain a written protocol to address any social, emotional, and environmental needs of the individuals related to the symptoms of their psychiatric illness.
The agency has had Individual #2's 12/22/22 physical examination since that date, that indicates they are now taking a psychotropic medication for a psychiatric diagnosis. The agency did not create a written plan to address the individual's symptoms until 1/16/23, did not update the individual's 1/14/23 assessment to indicate there is now a plan to address the symptoms or update the sections of the assessment that are affected by the change in needs, and did not send the written plan to the team until 1/16/23. At the time of the 2/22/23 inspection, the plan was still not included in the individual's individual plan, nor did the agency reach out to the creator of the plan to ensure the information is included in the individual plan. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | 1/16/23 Individual #2's (attachment #9) SEEN plan was sent to the Support Coordinator to be added to the plan. |
04/30/2023
| Implemented |
| 2380.173(1)(i) | Individuals #1 and #2's date of admission to the new facility was not recorded in their records. The date of admission in their records stated 2017, however the facility didn't provide services to individuals until 1/9/2023. | The name, sex, admission date, birthdate and Social Security number. | 2/24/23 Face sheets updated for Individuals #1 (attachment #10) and #2 (attachment #11) with transfer date to new Studio. |
03/24/2023
| Implemented |