Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.91(a) | Individual #1 was admitted to program on 5/1/2016. As of inspection date, the only available copy of his fire safety training was dated 10/19/2016, which is 4 months late. | 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 Program Specialist will ensure all new individuals have Fire Safety upon admission to the ATF. |
03/08/2017
| Implemented |
2380.111(a) | Individual #1 was admitted to program on 5/1/2016. The physical exams on file are dated 2/25/2015 and 12/20/2016. The 2015 exam exceeds 1 year prior to admission & the 2016 exam is almost 8 months late. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Specialist will obtain a copy of a physical before the individual starts and then will obtain a yearly physical there after. The Program Specialist will keep all documentation available on attempts to obtain the physical. |
03/08/2017
| Implemented |
2380.111(c)(2) | Individual #1's physical exam did not include this section. | The physical examination shall include: A general physical examination. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(3) | Individual #1's physical exam did not include this section. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(4) | Individual #1's physical exam did not include this section. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(5) | Individual #1's physical exam did not include this section. On individual #3's physical exam, this section was not filled in by her doctor. | 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. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(6) | Individual #1's physical exam did not include this section. On Individual #2's physical exam, this section was not filled in by his doctor. | 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. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(7) | Individual #1's physical exam did not include this section. On Individual #3's physical exam, this section was not filled in by her doctor. | 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. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(8) | Individual #1's physical exam did not include this section. | The physical examination shall include: Physical limitations of the individual. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(9) | Individual #1's physical exam did not include this section. | The physical examination shall include: Allergies or contraindicated medication. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(10) | Individual #1's physical exam did not include this section. On Individual #2's and Individual #3's physical exams, this section was not filled in by their doctors. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.111(c)(11) | On Individual #1's physical exam dated 12/20/2016 it states "As Tolerated" in the dietary section. Individual #1 is on a pureed diet. | The physical examination shall include: Special instructions for an individual's diet. | Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. |
03/08/2017
| Implemented |
2380.113(a) | Staff #1 was hired on 9/19/2016. She didn't have a physical exam until 9/22/2016. | 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. | All new hires will have a physical prior to starting work and two years there after |
03/08/2017
| Implemented |
2380.113(c)(2) | Staff #1 was hired on 9/19/2016. She didn't have a TB test until 9/23/2016. | 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 new hires will have their TB test completed before they start work and then every two years after. |
03/08/2017
| Implemented |