Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.20(a) | Staff #2, activities aide hired 11/9/21 did not receive a criminal history check until 8/9/22. Staff #3, CNA hired 3/1/22 did not receive a criminal history check until 8/9/22. Staff #4, activities aide hired 7/26/21 did not receive a criminal history check until 11/26/22. Staff #5, activities aide hired 11/22/21 did not receive a criminal history check until 11/26/22. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | Handi-Crafters will not allow hired staff to start employment until a Criminal History Check is received on that prospective employee. |
01/24/2023
| Implemented |
2380.58(b) | There was standing water located in the warehouse and the dining hall where individuals were eating. | Floors, walls, ceilings and other surfaces shall be free of hazards. | See attached invoice for repair of the roof above both the dining hall and the warehouse (Attachment #10). |
01/18/2023
| Implemented |
2380.67(a) | A lounge chair in the program room is ripped and should be replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The lounge chair that was damaged was removed and put into the dumpster. Another chair was purchased and put into the same location. (See Attachment #6) |
01/18/2023
| Implemented |
2380.111(c)(5) | Individual #1, 3/16/22 physical examination does not address their tuberculosis test, it only states to see immunization records attached and what is attached is a screen shot of a paper which lists tuberculosis results without any identifying information to show that these results belong to individual #1. | 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. | See Attachment #8 which is a copy of Individual #1¿s TB test. It indicates that the TB test was placed on 5/23/22,and read on 5/25/22. It also indicates that it was a negative test. This documentation is from PentaHealth Colonial Family Practice, and has Individual #1¿s name on the bottom left corner. |
01/25/2023
| Implemented |
2380.39(c)(6) | Staff #1, activities coordinator did not have training in the implementation of the individual plan. | 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. | Staff #1 and all program staff were trained by the Director in the Implementation of the individual plan. The training included a review of the parts of the individual plan that are especially important for staff that work directly with individuals. These sections of the plan included: ¿Like & Admire¿, ¿Know & Do¿, ¿Desired Activities¿, ¿Important To¿, and ¿What Makes Sense¿. Also included was medical information, Health and Safety, and the Outcomes Section. This training was completed on 1/25/23. (See Attachment #2 for the training sign in sheet.) |
01/25/2023
| Implemented |
2380.181(f) | Individual #2 did not have their assessment sent to the plan team at least 3o days prior to 1/14/22 individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Please see the attached email that was sent to Individual #2¿s team on December 1, 2022 attaching Individual #2¿s annual assessment (See Attachment #4). Also attached is the invitation to the ISP meeting noting that Individual #2¿s ISP meeting was on January 9, 2023 (See Attachment #5). This assessment was sent to the team more than 30 days before the ISP meeting. |
01/25/2023
| Implemented |