| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(a) | Staff #2 was hired on 4/4/22 and did not have a physical examination completed within 12 months prior to employment. | 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 # 2 had a physical completed prior to working for us however our Human Resources department could not find the copy of it and the company shut down prior to our Human resources department being able to obtain it. We have since sent staff #2 to a new provider for another physical. This was completed on 11/30/2022 |
11/30/2022
| Implemented |
| 2380.113(b) | Staff #1's annual physical examination was not dated by the physician. There was a fax date on the top of the document dated 5/28/2022, however the physical examination did not include the date that the physical examination was completed. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | Staff # 1's physical was from a provider that is no longer available and so since we could not get it properly dated and signed, we switched to a new provider and had staff # 1 obtain another physical. Her new physical was completed on 11/30/2022. |
11/30/2022
| Implemented |
| 2380.113(c)(3) | Staff #1's annual physical examination did not 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. | Staff # 1's physical was completed by a provider that is no longer operational, so we switched to a new provider. Since we could not have the old provider fix the physical to include free from communicable diseases, we had staff #1 obtain a new physical from the new provider that states free of communicable diseases. This occurred on 11/30/22. |
11/30/2022
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1, Individual #2, Individual #3, Individual #4 and Individual #5's annual assessments did not 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. | 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. | Individual # 1, #2, #3, #4, #5's annual assessments were updated to include comments about the progress or lack of progress that the individual has made in their motor and communication skills. |
11/30/2022
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1, Individual #2, Individual #3, Individual #4 and Individual #5's annual assessments did not include the following information: The individual's progress over the last 365 calendar days and current level in the following area 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. | Individual # 1, #2, #3, #4, #5's annual assessments were updated to include comments about the progress or lack of progress that the individual has made in their personal adjustment skills. |
11/30/2022
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1, Individual #3 and Individual #5's annual assessments did not include the following information: The individual's progress over the last 365 calendar days and current level in the following area: 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. | Individual # 1, #3, #5's annual assessments were updated to include comments about the progress or lack of progress that the individual has made in their socialization skills. |
11/30/2022
| Implemented |
| 2380.181(e)(13)(v) | Individual #1, Individual #3 and Individual #5's annual assessments did not include the following information: The individual's progress over the last 365 calendar days and current level in the following area: 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. | Individual # 1, #3, #5's annual assessments were updated to include comments about the progress or lack of progress that the individual has made in their motor recreation skills. |
11/30/2022
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1, Individual #3 and Individual #5''s annual assessments did not include the following information: The individual's progress over the last 365 calendar days and current level in the following area: 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. | Individual # 1, #3, #5's annual assessments were updated to include comments about the progress or lack of progress that the individual has made in their community-integration skills. |
11/30/2022
| Implemented |