Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00228541

Renewal

08/01/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.113(a)	Direct Service Worker #1 had a physical examination completed on 02/11/21, and then again on 05/12/23. This exceeds the every 2-year requirement.	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.	Goodwill of Southwestern Pennsylvania¿s Human Resources Department will notify all identified employees within 90 days that they are approaching their renewal date and that, upon expiration, will not provide direct service until recertifications have been completed and approved.	09/01/2023	Implemented
2380.181(e)(14)	Individual #1's initial assessment, dated 05/13/23, did not include an assessment of the individual's knowledge of water safety and ability to swim. Individual #2's annual assessment, dated 09/21/22, did not include an assessment of the individual's knowledge of water safety and ability to swim. Individual #3's annual assessment, dated 09/08/22, did not include an assessment of the individual's knowledge of water safety and ability to swim. Individual #4's initial assessment, dated 01/20/23, did not include an assessment of the individual's knowledge of water safety and ability to swim.	The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.	The initial assessment and annual assessment have been updated to reflect the identified missing information regarding the individuals' knowledge of water safety and ability to swim.	08/30/2022	Implemented

SIN-00210015

Renewal

08/16/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.20(c)	Direct Service Worker #1, date-of-hire is 6/6/22, had a Pennsylvania criminal history record check completed 1/12/21.	Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire.	All new staff will have a Pennsylvania and FBI criminal history check completed, with results, no more than 1 year prior to the staff¿s start date as well as all Goodwill of SWPA staff that have resigned and returned for employment or who have moved from another department or job position within the agency and are seeking employment with this program. If the staff cannot produce documentation of current history checks upon hire, new clearances will be required prior to issuing a start date to ensure quality of service	10/03/2022	Implemented
2380.111(c)(5)	Individual #1's tuberculin skin test via Mantoux method was read with negative results on 9/15/21 by a medical assistant.	. 111(d): 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, signed, and dated by a registered nurse or a licensed practical nurse instead of a license physicians, certified nurse practitioner or certified physician's assistant.	An individual may participate in services if the physical exam includes the Tuberculin skin test with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted, signed, and dated by only a registered nurse or a licensed practical nurse instead of a license physician, certified nurse practitioner or certified physician's assistant. If a Tuberculin skin test was not read by a licensed practical nurse instead of a license physician, certified nurse practitioner or certified physician's assistant, the individual and support team will be notified that services will be interrupted within 3 days if the issue is not corrected.	10/03/2022	Implemented
2380.111(c)(5)	Individual #2 had a tuberculin skin test via Mantoux method read with negative results on 9/14/17 and then again 9/11/20.	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.	An individual must show proof of Tuberculin skin test with negative results every 2 years prior to start date with Goodwill SWPA and while in service. A new individual will not be given a start date until proof of testing. Individuals currently in program, will be placed on interruption until they are compliant with proof of testing within the 2-year requirement	10/03/2022	Implemented
2380.113(c)(2)	Program Specialist #2's tuberculin skin test via Mantoux method was read with negative results on 2/25/22 by a medical assistant.	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.	All staff are required to submit a Tuberculin skin test with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted, signed, and dated by a registered nurse or a licensed practical nurse instead of a license physician, certified nurse practitioner or certified physician's assistant. Staff not in compliance will be given 3 days to submit a test that meets compliance requirements or will be required to be removed from working with individuals until rectified.	10/03/2022	Implemented
2380.181(e)(2)	Individual #3's 7/25/22 assessment does not include their dislikes.	The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests.	Program Specialists will ensure that the individual is asked all questions and that all areas of the assessment are completed accurately with detailed information, from the individual, of the individual¿s likes, dislikes and interests including vocational and employment interests.	10/03/2022	Implemented

SIN-00193425

Renewal

09/14/2021

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.59(b)	Hot water temperature measured 122.7 degrees Fahrenheit at the kitchen sink at 12:38 AM. The kitchen area is accessible to individuals [Repeat violation 10/15/2020].	Hot water temperatures in areas accessible to individuals may not exceed 120°F.	A work order was submitted requesting installation of a water temperature regulator, for the sink in the kitchen of the ATF, to ensure that the water temperature does not exceed 120 degrees Fahrenheit. The regulator was installed 9.15.2021and will be set to ensure the temperature of the water does not exceed 120 degrees Fahrenheit.	09/15/2021	Implemented
2380.111(c)(7)	The physical examination for individual #1, dated 4/17/21, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The physical examination for individual #2, dated 6/21/21, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.	The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.	The current physical form has been updated to include all 2380 licensing required information including a section specific to an assessment of the individual¿s health maintenance needs, medication regiment and the need for blood work at recommended intervals. For new clients, the completion of the Goodwill physical form or a physical form that is inclusive of all 2380 licensing requirements will be required for acceptance into the 2380 licensed program prior to start date by the Assistant Director of Disability Services. For current participants, the annual Goodwill physical form or a physical form that is inclusive of all 2380 licensing requirements for physicals will be required annually for continued provision of service in the 2380 licensed program. The program specialist will be required to document the acceptance and continued use of the authorized form.	10/15/2021	Implemented
2380.111(c)(8)	The physical examination for individual #1, dated 4/17/21 did not address the physical limitations of the individual. The physical examination for individual #3, dated 5/28/21 did not address the physical limitations of the individual.	The physical examination shall include: Physical limitations of the individual.	The current physical form has been updated to include all 2380 licensing required information including a section specific to the limitations of the individual. For new clients, the completion of the Goodwill physical or a physical form that is inclusive of all 2380 licensing requirements will be required for acceptance into the 2380 licensed program prior to start date by the Assistant Director of Disability Services. For current participants, the annual Goodwill physical or a physical form that is inclusive of all 2380 licensing requirements for physicals will be required annually for continued provision of service in the 2380 licensed program. The program specialist will be required to document the acceptance and continued use of the authorized form. The program specialist will be required to document the acceptance and continued use of the authorized form.	10/15/2021	Implemented
2380.111(c)(10)	The physical examination for individual #1, dated 4/17/21, did not address medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination for individual #2, dated 6/21/21, did not address medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination for individual #3, dated 5/28/21, did not address medical information pertinent to diagnosis and treatment in case of an emergency.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	The current physical form has been updated to include all 2380 licensing required information including a section specific to medical information pertinent to diagnosis and treatment in case of an emergency. For new clients, the completion of the Goodwill physical form or a physical form that is inclusive of all 2380 licensing requirements will be required for acceptance into the 2380 licensed program prior to start date by the Assistant Director of Disability Services. For current participants, the annual Goodwill physical form or a physical form that is inclusive of all 2380 licensing requirements for physicals will be required annually for continued provision of service in the 2380 licensed program. The program specialist will be required to document the acceptance and continued use of the authorized form.	10/15/2021	Implemented
2380.111(c)(11)	The physical examination for individual #1, dated 4/17/21, did not address special instructions for the individual's diet. The physical examination for individual #3, dated 5/28/21 did not address special instructions for the individual's diet.	The physical examination shall include: Special instructions for an individual's diet.	The current physical form has been updated to include all 2380 licensing required information including a section specific to the physical examination addressing any special instructions for an individual¿s diet. For new clients, the completion of the Goodwill physical form or a physical form that is inclusive of all 2380 licensing requirements will be required for acceptance into the 2380 licensed program prior to start date by the Assistant Director of Disability Services. For current participants, the annual Goodwill physical form or a physical form that is inclusive of all 2380 licensing requirements for physicals will be required annually for continued provision of service in the 2380 licensed program. The program specialist will be required to document the acceptance and continued use of the authorized form.	10/15/2021	Implemented
2380.113(a)	Staff #3 had a physical examination dated 3/30/2019 and again on 9/5/2021. A physical examination was not within the 2 years time frame.	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 are required to present an updated physical upon hire and every two years thereafter. Review of staff requirements will be conducted with HR quarterly to ensure that physicals are renewed within the 2 year required timeframe. Staff will not be permitted to work with clients if physicals ae not up to date.	11/01/2021	Implemented
2380.39(c)(2)	Annual training hours for Staff #1 did not encompass the following areas for the annual training year, dated 1/1/2020 through 12/31/2020: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the child protective services law, the Adult Protective Services Act.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.	Staff #1 will be assigned The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the child protective services law, the Adult Protective Services Act for this current training year and future training years as required	11/01/2021	Implemented
2380.39(c)(3)	The annual training for staff #1 and staff #2 did not encompass the following areas for the annual training year, dated 1/1/2020 through 12/31/2020: Individual rights.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.	Staff #1 will be assigned Individual Rights training for this training period. All staff are given until December 31st to complete all required trainings for the current training year. Trainings are assigned by quarter up until September. The last quarter is used to make up training not completed due to vacations, leave of absence etc. Staff will be asked to review their trainings quarterly to ensure they have completed all trainings. Trainings are assigned to each staff through Goodwill's internal agency training site Good To Grow. Staff #2 was furloughed during 3/28/2020- 6/9/2020 and again 12/7/2020- 3/21/21. Not knowing staff #2 would be furloughed she could not plan ahead to complete trainings that would occur in the quarter she was furloughed. Staff #2 did resume trainings between 6/9/2020 and 12/7/2020. And then again upon return 3/22/21 in the new training period. During COVID, furloughed staff were not expected to complete work related activities without pay. It is requested that staff furloughed during COVID closures be given a pass for completing some trainings as they were not working for the agency or working with clients.	11/01/2021	Implemented
2380.39(c)(4)	The annual training for staff #2 and staff #3 did not encompass the following areas for the annual training year, dated 1/1/2020 through 12/31/2020: Recognizing and reporting incidents.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.	All staff are given until December 31st to complete all required trainings for the current training year. Trainings are assigned by quarter up until September. The last quarter is used to make up training not completed due to vacations, leave of absence etc. Staff #2 was furloughed during 3/28/2020- 6/9/2020 and again 12/7/2020- 3/21/21. Not knowing staff #2 would be furloughed she could not plan ahead to complete trainings that would occur in the quarter she was furloughed. Staff #2 did resume trainings between 6/9/2020 and 12/7/2020. And then again upon return 3/22/21 in the new training period. During COVID, furloughed staff were not expected to complete work related activities without pay. It is requested that staff furloughed during COVID closures be given a pass for completing some trainings as they were not working for the agency or working with clients. Staff #3 was furloughed 3/18/2020 ¿ 6/29/2020 and then again 11/20/20 ¿ 7/6/21. Not knowing staff #3 would be furloughed he could not plan ahead to complete trainings that would occur in the quarter he was furloughed. Staff #3 resumed trainings upon his return the week of 7/6/21.	11/01/2021	Implemented
2380.39(c)(6)	The annual training for staff #2 did not encompass the following areas for the annual training year, dated 1/1/2020 through 12/31/2020: Implementation of the individual plan if the person works directly with an individual.	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.	All staff are given until December 31st to complete all required trainings for the current training year. Trainings are assigned by quarter up until September. The last quarter is used to make up training not completed due to vacations, leave of absence etc. Staff #2 was furloughed during 3/28/2020- 6/9/2020 and again 12/7/2020- 3/21/21. Not knowing staff #2 would be furloughed she could not plan ahead to complete trainings that would occur in the quarter she was furloughed. Staff #2 did resume trainings between 6/9/2020 and 12/7/2020. And then again upon return 3/22/21 in the new training period. During COVID, furloughed staff were not expected to complete work related activities without pay. It is requested that staff furloughed during COVID closures be given a pass for completing some trainings as they were not working for the agency or working with clients.	11/01/2021	Implemented

SIN-00177920

Renewal

10/15/2020

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.20(c)	Direct Service Worker #1's, date of hire 9/30/19, most recent Pennsylvania criminal history record check was completed in 2016.	Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire.	Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire. Human Resources will request FBI fingerprinting and background checks within 5 working days of the person¿s date of hire. Human Resources will collect documentation from the employee ensuring that staff completed the PA and FBI criminal History checks. Completed FBI fingerprinting and clearance dates will be entered into the digital employee file. If checks are not completed, the individual will be asked not to report to work until completed. If new hire provides a previous back ground check and FBI fingerprinting, Human Resources will verify that the previous checks and fingerprinting are within one year of projected start date. If not, Human Resources will request and submit a new background check. If staff are rehired, a new background check and FBI fingerprinting will be requested by Human Resources. As a second verification check, Disability Services will maintain a checklist of documentation as required by regulation 2380.20 ( C) to ensure that staff have completed the FBI fingerprinting and background checks. The compliance manager will review 25% of employee files two times per year with Human Resources to ensure compliance. The current status of this corrective action is that the Human Resources Information Specialist ( HRIS) is in the process of updating the digital employee database to store the above mentioned information digitally . The HRIS will complete the update and load the information into the digital employee file. The HRIS will train current HR staff on the new procedure. New HR staff will be trained within the first 30 days of employment. Furloughed HR staff will be trained upon return.	04/30/2021	Implemented
2380.59(b)	On 10/15/20 at 1:16PM the hot water temperature at the sink in the kitchen across from the program area, accessible to individuals measured 141.°F.	Hot water temperatures in areas accessible to individuals may not exceed 120°F.	Hot water temperatures in areas accessible to individuals may not exceed 120°F. Currently staff purchased a thermometer and were trained on 10/16/20 to check the water temperature , of the Aspire sink, 1- 2 times per day recording the results on a spreadsheet to be monitored by staff. Staff were trained to notify the maintenance department on any fluctuation in temperature immediately and completing a work order for documentation. On 10/15/20 a Work Order was submitted to agency maintenance department requesting a water temperature adjustment from 120°F from 141°F as per 2380.59(b). The work order was completed by the end of the business day 10/15/20. Disability Services will be notified of any future maintenance , additions or upgrades to equipment to the agency to ensure compliance measures are met.	11/03/2020	Implemented
2380.89(b)	The fire drill held on 6/25/19, did not have any individuals participate.	Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average.	Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average. The current status of fire drills is that the most current fire drill took place 10/26/ 20 at 11:55am during normal attendance and staffing conditions. The program was closed for the November Fire Drill and will resume with normal attendance and staffing conditions. The service of Community Participation Support requires that program participants are engaging in community activities at least 25% of the time while in program. The file drill that occurred, on 6/25/19, happened to occur while program participants and staff were attending community activities ( as verified by billing and attendance). Risk Management, has been trained to comply with 2380 .89 regulations by checking with staff that clients and staff are present.	10/26/2020	Implemented
2380.111(c)(3)	Individual #2's physical examination dated 3/11/20 did not include immunizations.	The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The status to date is that the Goodwill Physical Form for program participants is the only acceptable physical form. Program Specialists were trained, by the Program Compliance Manager, on 10/20/20 and 10/27/20 to utilize the Goodwill physical Form to ensure that all requirements are met under the 2380.111 including a record of current immunizations. For all new clients attending programming, a Goodwill Physical Form, included in the referral packet, will be required to be completed prior to program start date to ensure that all compliance measure are met upon program start. Staff will set a start date for services only after a completed physical is secured. All current clients requiring an updated physical are required to use the Goodwill Physical Form. Staff will send a reminder and blank Goodwill Physical Form to residential or caregiver prior to the annual physical date. Clients not having an updated physical, by the due date, will have an interruption in service until an updated physical is secured. The Goodwill Physical form includes all compliance requirements listed under 2380.111 regarding completion of the physical form. The Program Compliance Manger will ensure that 80% of files will be audited quarterly to include compliance requirements of physicals listed under 2380.111. Completion Date 4/30/21 to include staff currently furloughed due to COVID	04/30/2021	Implemented
2380.111(c)(5)	Individual #1, date of admission 1/29/20, had a Tuberculin skin test read on 7/2/19 and was not signed by a registered nurse, licensed practical nurse, licensed physician, certified nurse practitioner, or certified physician's assistant. Individual #2, date of admission 9/14/20, had a Tuberculin skin test administered 3/29/19; the results of the test was completed. Individual #3 had a Tuberculin skin test administered 3/18/19; the results of the test was not completed.[Repeat violation 6/11/19]	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.	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. The status to date is that the Goodwill Physical Form for program participants is the only acceptable physical form. Program Specialists were trained 10/20/20 and 10/27/20, by the Program Compliance Manager, to utilize the Goodwill physical Form to ensure that all requirements are met under the 2380. including the results of the TB test to be read, signed and dated prior to the expiration of the current form or test. For all new clients attending programming, a Goodwill Physical Form will be required to be completed prior to program start date to ensure that all compliance measure are met including the results of the TB test to be read , signed and dated prior to start. All current clients requiring an updated Physical or TB test will be required to use the Goodwill Physical Form including the results of the TB test to be read, signed and dated prior to the expiration of the current form or test. All TB positive skin tests will require an initial chest X-ray with results noted, signed and dated. The Goodwill Physical form includes all compliance requirements listed under 2380.111 regarding completion of the physical form including the TB test. The Program Compliance Manger will ensure that 80% of files will be audited quarterly to include compliance requirements of physicals listed under 2380.111 including timely TB tests. Completion Date 4/30/21 to include staff currently furloughed due to COVID	04/30/2021	Implemented
2380.111(c)(7)	Individual #2's physical examination dated 3/11/20 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank.	The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.	The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The status to date is that the Goodwill Physical Form for program participants is the only acceptable physical form. Program Specialists were trained, by the Program Compliance Manager 10/20/20 and 10/27/20, to utilize the Goodwill physical Form to ensure that all requirements are met under the 2380 including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. All sections of the physical form will be fully completed at the time of the physical. Physicals returned to Goodwill with any missing information will not be accepted as completed resulting in interruption of service or delay of start date for program. The Goodwill Physical Form is to be used to ensure compliance with required compliance measures as per 2380.111 including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Program Compliance Manager will ensure that 80% of files will be audited quarterly to include compliance requirements of physicals listed under 2380.111 including all section of the physical form are completed. Completion Date 4/30/21 to include staff currently furloughed due to COVID	04/30/2021	Implemented
2380.111(c)(10)	Individual #2's physical examination dated 3/11/20 did not include medical information pertinent to diagnosis and treatment in case of an emergency.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The status to date is that the Goodwill Physical Form for program participants is the only acceptable physical form. Program Specialists were trained,10/20/20 and 10/27/20, by the Program Compliance Manager, to utilize the Goodwill physical Form to ensure that all requirements are met under the 2380 regulations including medical information pertinent to diagnosis and treatment in case of an emergency. All sections of the client physical form will be fully completed at the time of the physical. Physicals returned to Goodwill with any missing information will not be accepted as completed resulting in interruption of service or delay of program start date. The Goodwill Physical Form is to be used to ensure compliance with required compliance measures as per 2380.111 including medical information pertinent to diagnosis and treatment in case of an emergency. The Program Compliance Manger will ensure that 80% of files will be audited quarterly to include compliance requirements of physicals listed under 2380.111 including all section of the physical form are completed. Completion Date 4/30/21 to include staff currently furloughed due to COVID	04/30/2021	Implemented
2380.113(a)	Direct Service Worker #1's, date of hire 11/12/18, had an initial physical examination completed 3/30/20.	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.	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. The current status is that Goodwill has revised the Goodwill Physical Form and has trained the HR Business Partner to begin using for current staff needing updated physicals. HR staff will be trained to ensure the Goodwill Physical Form is utilized and review the form and process with new and current staff. All staff will be required to complete a physical and TB test, with results, within 12 months of start date with the agency and every two years thereafter. Staff will be required to use the Goodwill Physical Form that includes all regulation2380.113 requirements. Human Resources will collect the completed physical form and enter the date of current and future required physicals in the digital employee file. Human Resources will contact and remind staff of upcoming physical due and send the required Goodwill Physical Form for completion. The compliance manager will review 25% of employee files two times per year with Human Resources to ensure compliance. Staff furloughed will be trained upon return.	04/30/2021	Implemented
2380.113(c)(3)	Direct Service Worker #1's physical examination, completed 3/30/20 did not address communicable diseases.	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.	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. HR staff has been trained to ensure the Goodwill Physical Form, which includes a signed statement that the staff is free of serious communicable diseases, is utilized and review the form and process with new and current staff. The current status of this action is that Goodwill has revised the Goodwill Physical Form and has trained the HR Business Partner to begin using for current staff needing updated physicals. Staff will be required to use the Goodwill Physical Form for required pre-employment physical that includes all regulation requirements including a signed statement that the person is free of serious communicable diseases, as defined in 28 Pa. Code § 27.2. Human Resources will collect the completed Goodwill Physical Form and enter the date of current and future required physicals in the digital employee file. The compliance manager will review 25% of employee files two times per year with Human Resources to ensure compliance.	04/30/2021	Implemented
2380.173(1)(ii)	Individual #1's record did not include identifying marks. Individual #2's record did not include identifying marks. Individual #4's record did not include identifying marks. [Repeat violation 6/11/19]	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.	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 status of this correction action is that the current staff were trained during the Program Specialists meetings, 10/20/20 and 10/27/20, on the completion of the face page to include race, height, weight, color of hair, color of eyes and identifying marks. The program specialist will complete a face page for each individual within 30 days of program start and annually thereafter. The face page includes a record of identifying marks as per 2380.173 (1) (ii). The Compliance Manager will audit the 30 day paperwork for new individuals to ensure that the face page is has no missing information. Additionally, 80% of client files will be audited quarterly by the Compliance Program Manager for any missing information required by 2380 regulations. Completion Date 4/30/21 to include staff currently furloughed due to COVID	04/30/2021	Implemented
2380.173(1)(iv)	Individual #1's record did not include religious affiliation. Individual #2's record did not include religious affiliation. Individual #4's record did not include religious affiliation.	Each individual's record must include the following information: Personal information including: Religious affiliation.	Each individual's record must include the following information: Personal information including: Religious affiliation.Plan of Correction:Each individual's record must include the following information: Personal information including: Religious affiliation.The status of this correction action is that the current staff were trained during the Program Specialists meetings, 10/20/20 and 10/27/20, on the completion of the face page to include race, height, weight, color of hair, color of eyes and identifying marks and religious affiliation2380.173 (1) (ii). The program specialist will complete a face page for each individual within 30 days of program start and annually thereafter. The face page includes a record of religious affiliation. The Compliance Manager will audit the 30 day paperwork for new individuals to ensure that the face page is has no missing information. Additionally, 80% of client files will be audited quarterly by the Compliance Program Manager for any missing information required by 2380 regulations. Completion Date 4/30/21 to include staff currently furloughed due to COVID	04/30/2021	Implemented

SIN-00157164

Renewal

06/11/2019

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.36(f)	Direct Service Worker #2, date of hire 7/25/15, was instructed in fire safety on 10/24/17 and then again on 10/30/18.	Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).	The agency provides annual fire safety training to participants and staff. There is an on-line OSHA approved training for staff as well. All staff training is documented in an internal web based training system, Cornerstone. The new supervisor will be trained to pull and review all staff transcripts biannually to ensure that staff are receiving required trainings including fire safety. Documentation of training reviews will be kept in the supervisors personnel file.	07/02/2019	Implemented
2380.91(a)	Individual #1, date of admission 10/9/18, was initially trained in fire safety on 10/29/18. Individual #2, date of admission 7/31/18, had fire safety training on 10/6/17 and then again on 10/26/18.	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.	Each participant will be instructed on fire safety upon admission and reinstructed annually. To ensure that all participants receive fire safety annually, each participant will be given a new orientation including fire safety and any other required trainings, when entering any new service within Goodwill. Fire safety is tracked annually using a spreadsheet. The spreadsheet will be reviewed when an individual returns from interruption to ensure that fire safety training is up to date. Risk management will include an alternative on-line training meeting OSHA regulations, in the event the participant misses the agency wide training. The new supervisor will be trained to include annual fire safety training when completing monthly individual file audits of 50% of files monthly for at least one year. Documentation of the audit will be kept in the File Review Folder. Incorrect documentation will be recorded and reviewed with the program manager and stored in the file review folder. Any repetitive errors will be addressed up to and including disciplinary action.	07/02/2019	Implemented
2380.111(a)	Individual #2, date of admission 7/31/18, had a physical examination on 5/11/17 and then again on 1/13/19 [Repeat Violation 6/12/18].	Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Program Specialist will sent a letter to all individuals, staff and caregivers at 90 days, 30 days and 1 month, if applicable, reminding them that their annual physical is due by the specified due date, found in the letter. The notification will include what is needed during the physical exam. Notification will also include the date of interruption of services if the physical is not completed on time or if any part of the physical is not competed. The letter will be kept in the file and copied to the supports coordinator and county, if applicable. The new supervisor will be trained to include a review of medical information when auditing at least 50% of files monthly. Missing documentation will be recorded and reviewed with the program manager and stored in the file review folder. Any repetitive errors will be addressed up to and including disciplinary action.	07/02/2019	Implemented
2380.111(c)(5)	Individual #2, date of admission 7/31/18, had a Tuberculin evaluation on 11/18/16 and then again 1/13/19 [Repeat Violation 6/12/18].	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.	The new supervisor will approve that a letter be sent to all individuals, staff and caregivers at 90 days and again at 30 days, if applicable, reminding them that Tuberculin skin testing is due by the specified due date, found in the letter. The notification will include that is the Tuberculin skin test is positive, that an initial x-ray with results should be noted on the physical. Notification will also include the date of interruption of services if the test is not completed on time. The letter will be kept in the file and copied to the supports coordinator and county, if applicable. The new supervisor will be trained to include a review of medical information when auditing at least 50% of files monthly. Documentation of the audit will be kept in the File Review Folder. Incorrect documentation will be recorded and reviewed with the program manager and stored in the file review folder. Any repetitive errors will be addressed up to and including disciplinary action.	07/02/2019	Implemented
2380.113(c)(3)	Program Specialist #1, date of hire 4/16/18, had a physical examination on 2/19/19; however, the physical examination did not include a statement that the employee is free from a communicable disease. This section of the form contained a question mark. [Repeat Violation 6/12/18].	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.	.All new staff shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Human Resources will be responsible to ensure that new staff shall have a physical examination along with documentation of that staff being free of serious communicable diseases and negative Tuberculin Skin Testing within 12months prior to employment and every 2 years thereafter. r. The hiring manager will notify the Human Resources Business Advisor two weeks prior to the new staffs orientation. The Human Resource Business Advisor will provide contact information and the Employee Physical Examination Report to the new hire requiring that the new hire bring the completed physical paperwork to orientation. Staff physicals will be tracked in the Human Services Information System to ensure that staff have completed physicals upon hire. It will also track dates to ensure a new physical is competed two years.The Supervisor will be able to access the Human Resource Information System Quarterly to ensure timely physicals. [Program specialist #1's physical examination was updated to include "no evidence of communicable disease." Immediately and upon completion, the CEO or designee educated in the requirements of staff persons' physical examinations shall audit all staff persons physical examination to ensure all required information is included. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/8/19)]	07/02/2019	Implemented
2380.173(1)(ii)	Individual #2'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 will complete all required fields of documentation, leaving no blanks. The new supervisor will be trained to audit 50% of individuals files for required documentation at least monthly for one year. The results of the audit will be kept in the Audit Review Folder and reviewed at each audit for repetitive errors. [Immediately, the CEO or designee shall update Individual #2's record to included identify marks. Documentation of aforementioned audits of individuals records shall be kept. (DPOC by AES,HSLS on 7/8/19)]	07/02/2019	Implemented
2380.181(a)	Individual #1, date of admission 10/9/18, had a functional assessment completed on 1/19/18 and then again on 3/1/19. Individual #2, date of admission 7/31/18, had a functional assessment completed on 2/22/18 and then again on 4/1/19. Individual #3, date of admission 7/3/17, had a functional assessment completed on 10/9/17 and then again on 11/19/18.	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.	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 and documented by a dated and signed copy in the participants file. All Program Specialists were required to review the 75 day policy on 7/2/2019. The program specialists use a spreadsheet calculating the due date of the assessments. The assessment will be signed by the individual and program specialists on the day of the assessment and provided to the SC or plan lead and plan team members at least 30 days prior to the ISP meeting. Documentation of the 30 days will be the dated scanned signed document. The spreadsheet includes a check box for signatures and completion date of the assessment. The new supervisor will be trained to audit monthly, for at least one year, a 50% sample of assessments for dates and signatures as well as correspondence documentation showing the program specialist has provided all individuals assessments to the plan team within 30 days of the ISP. Incorrect documentation will be recorded and reviewed with the program manager and stored in the file review folder. Any repetitive errors will be addressed up to and including disciplinary action. Documentation of the audit will be kept in the File Review Folder.	07/02/2019	Implemented
2380.181(f)	Individual #1's functional assessment, dated 3/1/19, was provided to plan team members on 3/1/19 for the ISP meeting on 3/1/19. Individual #2's functional assessment, dated 4/1/19, was provided to plan team members on 4/1/19 for the ISP meeting on 4/1/19. Individual #3's functional assessment, dated 11/19/18, was provided to plan team members on 11/19/18 for the ISP meeting 11/19/18. [Repeat Violation 6/12/18].	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).	Program Specialist was required to review the 75 day rule on 7-2-219. The program specialist is to use a spreadsheet calculating the due date of the assessments. The spreadsheet includes a check box for signatures and completion date of assessment. The assessment will be signed by the individual and program specialists on the day of the assessment and provided to the SC or plan lead and plan team members at least 30 days prior to the ISP meeting. Documentation of the 30 days will be the dated, scanned and signed document. The new supervisor will be trained to, at least monthly, audit a 50% sample of the completion of assessments for the signatures on the date of the assessment. The audit will include documentation showing the program specialist has provided all individuals assessments to the plan team within 30 days of the ISP. Incorrect documentation will be recorded and reviewed with the program manager and stored in the file review folder. Any repetitive errors will be addressed up to and including disciplinary action.	07/02/2019	Implemented
2380.186(a)	The program specialist did not complete an ISP review for Individual #1 that includes time period from 11/20/18 to 3/1/19. The program specialist did not complete an ISP review for Individual #2 that includes time period from 12/28/18 to 6/11/19. The program specialist did not complete an ISP review for Individual #3 that includes time period from 8/13/18 to 11/19/18.	The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.	The program specialist will complete an ISP review of services and expected outcomes for the ISP every 3 months (four times a year). A fourth quarter/ISP review check box will be added to the currently used Quarterly Review Form to ensure that a quarterly review is completed and documented for the fourth quarter/ ISP review meeting. The new supervisor will be trained to, at least monthly, for one year, audit a 50% sample of individuals files, for the previous year, to enure that at least four quarterly reviews are completed with the fourth being a part of the ISP review. Documentation of the audit will be kept in the File Review Folder. Incorrect documentation will be recorded and reviewed with the program manager and stored in the file review folder. Any repetitive errors will be addressed up to and including disciplinary action.	07/02/2019	Implemented
2380.186(d)	The program specialist provided Individual #1's ISP review, for review period 3/1/19 to 6/1/19, to the plan team members on 11/20/18. This document used a pre-populated date.	The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.	Program specialists will use a blank letterhead template, for each new letter, to ensure that correct and current information is reflected. The date will reflect that the information is being sent within the 30 calendar days after the ISP review meeting. The date of the review meeting will be documented in the body of the letter. A sample of an additional three files were audited for accuracy on the date, on similar documents and was found to be in compliance. The new supervisor will be trained to audit 50% of the files monthly to ensure that dates, signatures and information are correct. Incorrect documentation will be recorded and reviewed with the program manager and stored in the file review folder. Any repetitive errors will be addressed up to and including disciplinary action.	07/02/2019	Implemented

SIN-00136720

Renewal

06/12/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
20.21(b)	On 6/12/18, at 10:00AM, one direct service worker was providing services for six individuals who attend the adult training facility in a room on the second floor of the facility. Interview revealed that this area is used about once or twice a week to provide services to individuals. This area of the facility is not licensed.	The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued.	As of 6/13/18 Goodwill has not and will not provide any 2380 services in any unlicensed areas of the workforce development center. All 2380 staff and management have been retrained on the meaning of this regulation.	06/13/2018	Implemented
2380.89(d)	The eleven fire drills completed between 7/19/17 and 5/2/18 had evacuation times which varied between 4 minutes and 4 minutes 50 seconds. There was no written documentation by a firesafety expert within the past year which specified an evacuation time exceeding 2 1/2 minutes.	Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.	On 6/15/18 Frances P. Sehn, VP of Risk Control and Claims Advocacy, at Willis Towers Watson insurance company, holding the credentials of MS, CSC, and ARM visited the Goodwill facility in Lawrenceville to redo and adjust our fire safety inspection. Mr. Sehn provided Goodwill with an updated fire inspection summary report, on his company letterhead, with his signature and credentials, on 6/27/18, which states that the 2380 group should have an extended evacuation time of 4 minutes and 30 seconds due to our building and program setup. In addition we have revised our 2380 fire drill roster to document the actual time that just the 2380 program takes to exit the building, instead of using the time of the entire building evacuation. There was a fire drill on 6/19/18 which all 2380 program participants were evacuated in 51 seconds. One on 7/12/18, which all were evacuated in 55 seconds. One on 8/27/18, which all were evacuated in 35 seconds, and one on 9/2/18, where all were evacuated in 28 seconds.	06/19/2018	Implemented
2380.111(a)	Individual #1 had a physical examination completed on 9/16/16 and then again on 10/27/17. [Repeat violation 7/6/17]	Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Individual 1 and her team were informed at her ISP meeting on 6/14/18 that she will need updated immunization records as soon as possible as well as a new physical by 10/27/18 to hopefully avoid this situation in the future. Several follow phone calls were made as well in regards to the immunizations still needed, including one on 9/28/18 reminding the mother that a new physical is due within the month and informing her that a reminder letter and physical form was sent via US Mail on 9/27/18 with detailed information of what is needed. Mom confirmed that an appointment was set for October but was not able to confirm the date over the phone. Moving forward the program specialist will send a reminder 3 months prior to a physical due and then another one month before the physical is due including a physical form to have filled out that includes all needed information. The program specialist has created a spreadsheet that details these due dates and allows for them to be checked off as the reminders are sent. Also all reminders made will be documented on the spreadsheet.[Upon submission of individuals' physical examinations and at least quarterly, the designated staff person shall update the aforementioned tracking system to ensure individuals' physical examinations are completed, timely. (DPOC by AES,HSLS on 10/1/18)]	09/28/2018	Implemented
2380.111(c)(3)	Individual #1's physical examination, completed 10/27/17, did not include immunizations. Individual #2's physical examination, completed on 7/25/17, indicated that the most recent immunizations were given on 12/29/98. [Repeat violation 7/6/17]	The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	After confirming with licensing that Tdap is the only immunization that is sited for being late or undocumented the program specialist was trained and she added it to her checklist to ensure she is reminding families in a timely manner if an updated immunization is needed. Program specialist did a full audit of 2380 program participants for immunizations on 6/19/18 and is diligently working on making sure all participants have this record in their file. As of 9/28/18, 18 of 21 individuals are in compliance with this regulation and 3 individuals were sent letters in June and updated letters on 9/28/18 reminding them they they must get this immunization record to us as soon as possible. Individual #1 has an upcoming physical in October and her mother has been made aware that the Tdap is required. She intends to take care of it at that time. Many attempts have been made to obtain this information in the meantime, including at her ISP on 6/14/18. Individual #2 handed in a completed physical on 7/24/18 which includes his Tdap completed on 7/24/18. [Upon submission of physical examinations, a designated staff person trained in the requirements of individual physical examinations, shall audit all individuals' current physical examinations to ensure all required information is included and follow up as needed. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/1/18)]	09/28/2018	Implemented
2380.111(c)(5)	Individual #3, admission date 11/6/17, did not have a Tuberculin skin test with negative results. [Repeat violation 7/6/17]	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.	Individual #3 had a negative TB reading on 10/23/17 and it is now in her file. Upon this review it was discovered that there was a gap with current Goodwill clients in other programs transitioning to 2380 regulated programming without a documented TB done before their first day. All program specialist were trained on this regulation and made aware of the gap on 6/22/18 by Maryn Haberle to prevent this happening in the future. [Upon submission of physical examinations, a designated staff person trained in the requirements of individual physical examinations, shall audit all individuals' current physical examinations to ensure all required information is included and follow up as needed and available upon request by the Department. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/1/18)]	09/28/2018	Implemented
2380.111(c)(10)	Individual #2's physical examination, completed on 7/25/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #4's physical examination, completed on 7/25/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	Individual # 2 handed in a physical completed on 7/24/18 on our physical form that does include diagnosis information. Individual #4 handed in a physical completed 8/20/18 on our physical form that does include diagnoses information. This issue will not occur in the future due to us sending out our physical form that list a space for diagnostic information, which what was used in both of the above examples, at least a month ahead of the physical due date, as well as the fact that the program specialist was trained on 6/13/18 by Maryn Haberle to look for this information specifically when a physical comes in. [Upon submission of physical examinations, a designated staff person trained in the requirements of individual physical examinations, shall audit all individuals' current physical examinations to ensure all required information is included. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/1/18)]	08/20/2018	Implemented
2380.113(a)	Program Specialist #1, date of hire 4/16/18, had a physical examination completed on 4/30/18. Direct Service Worker #2, date of hire 2/26/18, had a physical examination completed on 3/6/18.	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.	Department hiring managers and HR were informed by Maryn Haberle on 6/13/18, that all new staff coming in under 2380 regulations must have their physical with all required information and TB test results turned in before they start on their first official day. The hiring manager for the ATF updated her hiring checklist with these items. We have had one new hire since, Amy Noble, whose hire date was 8/6/18, physical date was 7/25/18, and TB reading date was 7/27/18 which shows the efforts have been successful.	06/13/2018	Implemented
2380.113(c)(2)	Program Specialist #1, date of hire 4/16/18, had a Tuberculin skin test read on 4/19/18.	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.	Department hiring managers and HR were informed by Maryn Haberle on 6/13/18, that all new staff coming in under 2380 regulations must have their physical with all required information and TB test results turned in before they start on their first official day. The hiring manager for the ATF updated her hiring checklist with these items. We have had one new hire since, Amy Noble, whose hire date was 8/6/18, physical date was 7/25/18, and TB reading date was 7/27/18 which shows the efforts have been successful.	06/13/2018	Implemented
2380.113(c)(3)	Direct Service Worker #3's physical examination, completed on 4/11/18, did not indicate if the staff person is free from communicable disease.	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.	Department hiring managers and HR were informed by Maryn Haberle on 6/13/18, that all new staff coming in under 2380 regulations must have their physical with all required information (including free from communicable disease statement) and TB test results turned in before they start on their first official day. The hiring manager for the ATF updated her hiring checklist with these items including the free from communicable disease statement . We have had one new hire since, Amy Noble, whose hire date was 8/6/18, physical date was 7/25/18, and TB reading date was 7/27/18 which shows the efforts have been successful. Direct Service Worker #3 has changed positions and as not required to redo her physical. [Upon submission of physical examinations, a designated staff person trained in the requirements of staff persons physical examinations, shall audit all staff persons' current physical examinations to ensure all required information is included. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/1/18)]	06/13/2018	Implemented
2380.181(d)	Individual #1's assessment completed on 5/14/18 was not signed and dated by a program specialist.	The program specialist shall sign and date the assessment.	In a staff meeting on 6/22/18 all program specialists were retrained by Maryn Haberle on the importance of making sure all assessments are signed and dated and that the signed assessments make it into the files. There was also an audit performed on a sample of 6 files using the audit form with the added check boxes. All files were in compliance for this regulation.[At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of individuals' assessments to ensure the program specialist(s) have signed and dated all individuals' assessments. Documentation of the audits shall be kept. (DPOC, by AES, HSLS on 10/1/18)]	06/22/2018	Implemented
2380.181(f)	The program specialist did not provide Individual #4's assessment, completed 8/4/17, to the plan team members at least 30 calendar days prior to the ISP meeting held 9/1/17.	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).	All program specialists were informed of the new 75 day policy, which is detailed in the last POC submission, at our meeting on 6/22/18, by Maryn Haberle. The program specialist under 2380 created a spreadsheet calculating when each assessment should be done to meet the 75 day rule to ensure there is never a late assessment again due to any reason. [At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of correspondence documentation showing the program specialist has provided all individuals' assessments to the plan team members at least 30 calendar days prior to the ISP meetings. Documentation of audits shall be kept. (DPOC by AES, HSLS on 10/1/18)]	06/22/2018	Implemented
2380.186(b)	Individual #2's ISP review end dated 4/9/18 was not signed by the program specialist and the individual.	The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.	In a staff meeting on 6/22/18 all program specialists were retrained by Maryn Haberle on the importance of making sure all reviews are signed and that the signed reviews make it into the files. There was also an audit performed on a sample of 6 files using the audit form with the added check boxes. All files were in compliance for this regulation. [At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of individuals ISP reviews for past 6 months to ensure the program specialist and individual have signed and date the ISP reviews upon review of the ISP, timely. Documentation of the audits shall be kept. (DPOC, by AES, HSLS on 10/1/18)]	06/22/2018	Implemented

SIN-00116961

Renewal

07/06/2017

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.91(a)	Individuals #1, #2 and #3 were instructed in fire safety on 10-8-15 and again on 10-26-16.	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.	The Director of Risk Management was informed that individual fire safety training must be completed each year on or before the date it was completed the year prior to meet 2380 requirements. The Program Specialist was also informed and will work with Risk Management each year to ensure this happens. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure individuals are instructed in fire safety as required, timely. At least quarterly for 1 year, the CEO or designee shall review the tracking document to ensure timely completion of fire safety instruction. (AS 7/19/17)]	07/17/2017	Implemented
2380.111(a)	Individual #1, date of admission 1-23-17 had a physical examination on 3-25-15 and then again on 4-12-17.	Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.	The physical for individual #1, dated 3/23/16, was obtained from Ben Violet at Allegheny County. Since this was not discovered during an internal audit more detail was added to the file content checklist to ensure more attention in paid to the dates on the physicals. Program Specialists were also reminded that they may contact staff at Allegheny County for missing physicals. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure individuals' have a physical examination within 12 months prior to admission and annually thereafter. At least quarterly for 1 year, the CEO or designee shall review the tracking document to ensure timely completion individuals' physical examinations. (AS 7/19/17)]	07/17/2017	Implemented
2380.111(c)(3)	Individual #3's physical examination, dated 3-27-17 did not include immunizations.	The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	Goodwill will develop it's own physical template for the ATF that includes immunization records and all other required information per 2380's, instead of relying of generic doctor office forms that may not include all required information. These forms will be handed out annually, a month before each individuals due date. [Immediately, the CEO or designee shall obtain an updated physical examination for individual #1 to include immunizations. Within 30 days of receipt of the plan of correction and upon completion thereafter, the CEO or designee shall review all individuals' physical examination to ensure all required information is included and there are not any areas of required information left blank; missing information shall immediately be obtained. Documentation of reviews shall be kept. (AS 7/19/17)]	07/17/2017	Implemented
2380.111(c)(5)	Individual #4, date of admission 4-11-16 had Tuberculin skin testing on 4-22-16.	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.	A new procedure will be implemented that requires the result of a negative TB test before admission into the ATF, for both new and current Goodwill clients, with no exceptions. A disclaimer will be added to the ATF referral form and the program and intake specialist have been informed of this change. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure individuals' have a physical examination to include all required information including Tuberculin skin testing within 12 months prior to admission and annually thereafter. At least quarterly for 1 year, the CEO or designee shall review the tracking document to ensure timely completion of individuals' physical examinations. (AS 7/19/17)]	07/17/2017	Implemented
2380.181(e)(14)	Individual #3's assessment, dated 1-30-17 did not include the individual's knowledge of water safety.	The assessment must include the following information: The individual's knowledge of water safety and ability to swim.	Individual 3's assessment has been updated on the proper form which includes knowledge of fire safety. The Program Specialist was retrained on the fact that the ATF specific annual assessment must be used even if an individual is involved in dual programming, like Individual #3. The ATF specific Program Specialist will delete all other program area assessments fro her computer to alleviate the confusion as well. Also, more detail will be added to the file audit checklist to make sure co-workers and supervisors auditing the ATF files are aware there is more info required for the assessments under 2380 regulations than the assessments from other program areas. [Immediately and continuing at least quarterly for 1 year, the Program Specialist(s) shall review all individuals' current assessments to ensure all required information is included as per 2380.181(e)(1)-(14). At least semi-annually for 1 year, the CEO or designee shall review a 25% sample of individual assessment to ensure all required information is included as per 2380.181(e)(1)-(14). Documentation of reviews shall be kept. (AS 7/19/17)]	07/17/2017	Implemented

SIN-00092571

Renewal

07/01/2016

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.173(1)(ii)	The record for Individual #1 did not include hair color, eye color, or identifying marks. The record for Individual #2 did not include hair color, eye color, or identifying marks. The record for Individual #3 did not include hair color or identifying marks. The record for Individual #4 did not include Hair color, eye color, or 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.	A program face sheet has been developed and added to the file content checklist. Each person will have this face sheet filled out upon entry into the program. The 4 individuals' face sheets mentioned in this POC will be sent via email to the inspector. [The records for Individuals #1, #2, #3, and #4 were updated on 7/25/16 to include hair color, eye color, identify marks and religious affiliation. Immediately and prior to admission and at least semi-annually, the program specialist will review all individual records to ensure all required personal information is included and will update as needed. Documentation of review shall be kept. (AS 8/2/16)]	07/15/2016	Implemented
2380.173(1)(iv)	The records for Individual #1, Individual #2, Individual #3, and Individual #4 did not include religious affiliation.	Each individual's record must include the following information: Personal information including: Religious affiliation.	A program face sheet has been developed and added to the file content checklist. Each person will have this face sheet filled out upon entry into the program. The 4 individuals' face sheets mentioned in this POC will be sent via email to the inspector.[The records for Individuals #1, #2, #3, and #4 were updated on 7/25/16 to include hair color, eye color, identify marks and religious affiliation. Immediately and prior to admission and at least semi-annually, the program specialist will review all individual records to ensure all required personal information is included and will update as needed. Documentation of review shall be kept. (AS 8/2/16)]	07/15/2016	Implemented

SIN-00079625

Initial review

06/26/2015

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
2380.62	The telephone numbers for the nearest hospital, police department, fire department and ambulance were not posted on or near the telephone in the smaller program area.	Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.	Stickers have been printed and posted to phones with an outside line of the nearest hospital, police dept., fire dept., ambulance and poison control center.	07/02/2015	Implemented
2380.69(e)	The men's and women's bathrooms in the hallway did not have covered trash receptacles.	Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.	A covered trash receptacle has been purchased and placed in the men's and women's bathroom in the hallway outside of the program area.	07/02/2015	Implemented