| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Alpet surface sanitizing wipes were unlocked in the dining area. Home select pine cleaner, Lucky antibacterial hand soap, Renewal sunscreen, and Rite Aid sunscreen were unlocked in a grey filing cabinet in the main training area.
| Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Steve Schafebook , Adult Day program supervisor had a meeting with the ATF staff regarding the poisonous materials. Brenda Hartman Developmental trainer 1 remove items from the drawer and placed in a locked closet. The filing cabinet still has something's in the drawer which is locked at all time and the key is removed. This drawer is checked on several times a day to ensure that it is being locked. A reminder of poisonous materials was also placed in each staff members mailbox. |
09/12/2016
| Implemented |
| 2380.55(a) | There was a strong urine odor in the men's restroom. | Clean and sanitary conditions shall be maintained in the facility. | The bathrooms are now getting cleaned at minimum two times per day. There is a signature sheet that has been placed on the back of the door to note when the bathrooms have been cleaned. We have purchased a new deodorizer system that has also been installed to help control the odor. |
08/31/2016
| Implemented |
| 2380.55(d) | Two kitchen trash cans did not have lids to prevent the penetration of insects. | Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents. | Elizabeth Hershey, put in a work order to have the air conditioning issue looked into. We have tried turning up the temperature and closing the doors. That was a temporary fix. SJ Moyers were called in for a consultation and it was determined that the ac ducts need to be wrapped in insulation to help stop the dripping from condensation. At this time the supplies are have been ordered and will be installed upon the arrival of materials. |
10/31/2016
| Implemented |
| 2380.58(b) | The air conditioning ductwork in the main program area was dripping onto the floor. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Elizabeth Hershey, put in a work order to have the air conditioning issue looked into. We have tried turning up the temperature and closing the doors. That was a temporary fix. SJ Moyers were called in for a consultation and it was determined that the ac ducts need to be wrapped in insulation to help stop the dripping from condensation. At this time the supplies are have been ordered and will be installed upon the arrival of materials. |
10/31/2016
| Implemented |
| 2380.59(b) | The water temperature in the men's restroom was 126 degrees. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | Elizabeth Hershey completed a work order. Work order had been completed as of 9/1/2016. Going forward the water temp should be checked with each fire drill and as needed. An attachment will follow in an email. |
09/01/2016
| Implemented |
| 2380.63(b) | The second stall in the women's restroom did not have a lock on the door. The bottom dresser drawer in the main program area was missing handles. | Screens, windows and doors shall be in good repair. | Verna Morris put a work order in to have a new lock placed on the door. Pictures to be sent via email. |
09/01/2016
| Implemented |
| 2380.89(d) | The 8/12/15 fire drill log indicated an evacuation time of 4 minutes. The 11/25/15 fire drill log indicated an evacuation time of 3 minutes and 23 seconds. The 3/9/16 fire drill log indicated an evacuation time of 5 minutes and 36 seconds. The 5/20/16 fire drill log indicated an evacuation time of 2 minutes and 51 seconds. | 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. | Elizabeth Hershey updated out fire safety portion of the All Hazard Emergency plan to include more details. The fire safety she was completed to show compliance and a new form was developed to have a second check on the completed form. All staff have been informed that we no longer have unlimited amount of time to evacuate the building that was told to us at a previous licensing. |
09/01/2016
| Implemented |
| 2380.89(g) | REPEATED VIOLATION- 6/22/15 The 2/2/16 fire drill log did not indicate if all individuals met at the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Elizabeth Hershey updated out fire safety portion of the All Hazard Emergency plan to include more details. The fire safety she was completed to show compliance and a new form was developed to have a second check on the completed form. |
09/01/2016
| Implemented |
| 2380.111(a) | Individual #3's 2/11/16 physical exam was completed late. The previous exam was completed on 1/25/15. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that an individual has 10 days after the current physical runs out before they need to have one handed into QUEST. In the event that a physical is not obtained, services would be suspended until one is completed. |
09/12/2016
| Implemented |
| 2380.111(b) | Individual #1's 12/17/15 physical exam was not dated by the physician. | The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | A letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that a physical has to have all areas completely filled out. in the event that a physical is returned with blank spaces, it will be sent back to the PCP. If the individual does not have a completed physical after the 10 day grace period services will be suspended. |
09/12/2016
| Implemented |
| 2380.111(c)(1) | Individual #2's 3/8/16 physical exam did not inlcude a medical history. | The physical examination shall include: A review of previous medical history. | A letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that a physical has to have all areas completely filled out. in the event that a physical is returned with blank spaces, it will be sent back to the PCP. If the individual does not have a completed physical after the 10 day grace period services will be suspended. |
09/12/2016
| Implemented |
| 2380.111(c)(3) | Individual #2's 3/8/16 physical exam did not include dates of immunizations. Individual #1's 12/17/15 physical exam did not include dates of immunizations. The last tetanus/diphtheria immunication in the record was dated 6/22/06. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | A letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that a physical has to have all areas completely filled out. in the event that a physical is returned with blank spaces, it will be sent back to the PCP. If the individual does not have a completed physical after the 10 day grace period services will be suspended. |
09/12/2016
| Implemented |
| 2380.111(c)(5) | Individual #1's tuberculin test was completed on 12/3/12. Individual #2's 7/12/16 tuberculin test was completed late. The precious testing was completed on 5/2/14. | 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 letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that a physical has to have all areas completely filled out. in the event that a physical is returned with blank spaces, it will be sent back to the PCP. If the individual does not have a completed physical after the 10 day grace period services will be suspended. A TB test should be completed every two years. |
09/12/2016
| Implemented |
| 2380.111(c)(6) | Individual #2's 3/8/16 physical exam did not include a communicable disease status. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | A letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that a physical has to have all areas completely filled out. In the event that a physical is returned with blank spaces, it will be sent back to the PCP. If the individual does not have a completed physical after the 10 day grace period services will be suspended. |
09/12/2016
| Implemented |
| 2380.111(c)(8) | Individual #1's 12/17/15 physical exam does not include physicial limitations. | The physical examination shall include: Physical limitations of the individual. | A letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that a physical has to have all areas completely filled out. in the event that a physical is returned with blank spaces, it will be sent back to the PCP. If the individual does not have a completed physical after the 10 day grace period services will be suspended. |
09/12/2016
| Implemented |
| 2380.111(c)(10) | Individual #1's 12/17/15 physical exam did not include 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. | A letter that will be sent home to each individual, a copy will be attached to the physical and also added to the participant hand book was created by Steve Schafebook. this letter address that a physical has to have all areas completely filled out. in the event that a physical is returned with blank spaces, it will be sent back to the PCP. If the individual does not have a completed physical after the 10 day grace period services will be suspended. |
09/12/2016
| Implemented |
| 2380.173(1)(iii) | Individual #1's record did not include his/her primary language. | Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English. | Individual #3's file has been updated to state that her native language is not English and that her primary language is Arabic. She is able to understand English, but is not able to always express herself appropriately in English. |
09/01/2016
| Implemented |
| 2380.173(1)(v) | Individual #2's record did not include a dated photograph. Individual #1's photo in the recod was not dated. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | Michele Umberger Executive Assistant printed out 5x7 colored picture and the individual's name and the date was placed on the page. This will be placed in the front of each individuals file. Attachment to be sent via email. |
09/01/2016
| Implemented |
| 2380.173(6)(ii) | Individual #3's record did not include a signature page from the 2/5/16 Individual Support Plan meeting. | Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting. | During a program specialist meeting it was reviewed that if a program specialist does not receive things such a signature sheet, or any materials from an ISP review we need to request these items to keep our file current. In the event that we do not receive one we will still have the request that we sent over to the IDSC. |
09/01/2016
| Implemented |
| 2380.173(7) | Individual #3's record did not include a complete, current copy of the Individual Support Plan. | Each individual¿s record must include the following information: A copy of the current ISP. | During a program specialist meeting it was reviewed that we need to have a current copy of the individual's ISP in their file at all times. In the event that we do not receive one we will still have the request that we sent over to the IDSC. |
09/01/2016
| Implemented |
| 2380.181(e)(3)(i) | Individual #1's 4/19/16 assessment did not include functional skills. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Acquisition of functional skills. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual progress and growth will address the acquisition of functional skills. |
09/12/2016
| Implemented |
| 2380.181(e)(7) | Individual #1's 4/19/16 assesment and Individual #3's 9/5/15 assessment did not include his/her ability to move away from heat sources. | 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. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual will note the individuals awareness of the heat source and their knowledge of what to do if there is a potential heat source. |
09/12/2016
| Implemented |
| 2380.181(e)(9) | Individual #1's 4/19/16 assessment and Individual # 3's 9/5/15 assessment did not include documentation of disability. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual's disabilities were documented and will include functional and medical limitations. |
09/12/2016
| Implemented |
| 2380.181(e)(10) | Individual #2's 12/24/15 assessment did not include a lifetime medical history. Individual #3's 9/5/15 assessment did not include an updated lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual's lifetime medical history attached or inserted. |
09/12/2016
| Implemented |
| 2380.181(e)(12) | Individual #1's 4/19/16 assessment did not include recommendations for specific areas of training, programming, or employment. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section recommendations for specific areas of training or advancement in to other programs. |
09/12/2016
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1's 4/19/16 assessment did not include progress over the past year in motor and communication skills. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual's motor and communication skills will be noted. |
09/12/2016
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1's 4/19/16 assessment did not include progress over the past year in personal adjustment. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual's personal adjustment will be reviewed over the past 60 days or year. |
09/12/2016
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's 4/19/16 assessment did not include progress over the past year in socialization. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual's socialization will be reviewed. |
09/12/2016
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's 4/19/16 assessment did not include progress over the past year in recreation. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual's recreation while in the program will be documented. |
09/12/2016
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's 4/19/16 assessment did not include progress over the past year in community-integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | Elizabeth Hershey revised the assessment that we were using. The new assessment has helpful reminders and guidelines of what needs to be in the narrative. The revised assessment was sent and helpful hints were added. The assessment was given to program specialist Steve Schafebook to use starting on 2/12/2016. In this section the individual's community integration and their progress and growth in this area over the past year. |
09/12/2016
| Implemented |
| 2380.183(5) | Individual #1's Individual Support Plan (ISP) did not include a social, emotional, environmental needs plan. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | This was for individual #3 not #1. Steve Schafebook located individual #3's SEEN plan and has placed it in his file behind the current assessment. |
09/01/2016
| Implemented |
| 2380.183(7)(i) | Individual #1's and Individual #3's Individual Support Plan did not include potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | An addendum was completed and sent over to the IDSC to include a paragraph stating what the potential is for the individual's to advance into this area. |
09/01/2016
| Implemented |
| 2380.183(7)(ii) | Individual #1's Individual Support Plan did not include potential to advance in community involvement. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Community involvement. | During a program specialist meeting this issue was discussed. When completing monthly and quarterly reviews it is important to note the areas in the community they have visited and to what degree they participated in the activities while out in the community. |
09/01/2016
| Implemented |
| 2380.183(7)(iii) | Individual #1's and Individual #3's Individual Support Plan did not include potential to advance in competitive employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | An addendum was completed and sent over to the IDSC to include a paragraph stating what the potential is for community- integrated employment. |
09/01/2016
| Implemented |
| 2380.185(b) | Individual #1's Individual Support Plan (ISP) includes a communication outcome. This outcome was not implemented. | The ISP shall be implemented as written. | At a Program Specialist meeting, Elizabeth Hershey reviewed that we need to know what outcomes are listed in the ISP so we are able to properly document the correct outcomes. |
09/01/2016
| Implemented |
| 2380.186(c)(1) | Individual #1's 6/9/16, 3/9/16, 12/9/15 and 9/10/15 Individiual Supprt Plan (ISP) reviews did not include progress on the independence outcome. A monthly review of Individual #3's outcome did not occur. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | During a program specialist meeting this issue was discussed. When completing it is important to note all outcomes that need to be reviewed. Anything that is listed as an outcome needs to be reviewed monthly and quarterly. |
09/01/2016
| Implemented |
| 2380.186(c)(4)(iii) | Individual #1 has not made progress on the independence outcome in the Individual Support Plan. Individual #1 did not want to work on this outcome. The program specialist did not recommend a change to the outcome to the supports coordinator. | The ISP review must include the following: The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. | At a Program Specialist meeting, Elizabeth Hershey reviewed with all involved that at any time an outcome can be changed due to lack of interest, or progress (good or bad) can be changed at any time. To Change a outcome an addendum should be completed and forwarded to the individuals IDSC. These changes have to be discussed by the individual and the program specialist to change the assigned outcome. |
09/01/2016
| Implemented |