Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228798 Renewal 08/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.69(e)The bathroom in the back room did not have paper towels. The agency did correct this at the time of the inspection.Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.During the inspection staff immediately restocked the bathroom. 08/23/2023 Implemented
2380.70(d)The first aid kit in the kitchen area did not have gauze tape. The agency did correct this at the time of inspection.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.During the inspection staff immediately placed new gauze tape in the first aid kit. 08/23/2023 Implemented
2380.111(a)Each individual shall have a physical exam within 12 months prior to admission and annually thereafter. Individual #2 date of admission was 2/28/22, their initial medical exam was completed on 3/1/22 and the following exam was not completed until 4/14/23. The dates of the physicals exceed the time frame required by the regulation.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Goodwill reviewed the admission package to ensure all required paperwork is included. We also created a checklist for staff to use. 09/08/2023 Implemented
2380.111(c)(4)Individual #1 physical dated 1/12/23 did not have a vision and hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Goodwill retrained Administrative Staff on the requirements of the physical for each individual. Included in this was the fact the no individual can be admitted or continue service is the physical in not completed in its entirety. 09/08/2023 Implemented
2380.113(c)(2)Staff #1 had a physical exam on 2/20/23 at which time a TB test was administered. However, staff did not go back to have the TB test read; therefore, there are no results on file.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.Staff #1 was immediately sent to receive a TB test. When asked for the reading on this test he explained that he did not get is completed. He was then immediately removed for the program area and directed to leave and he could not return to work until the test was completed. He has not returned to work. 09/11/2023 Implemented
2380.181(d)Individual #1 annual assessment was not dated and signed by the program specialist.The program specialist shall sign and date the assessment.Individual #1 did have a signed and dated assessment but was incorrectly placed in their service book. The Program Specialist for Individual #1 was not on site when the inspection happened and could not give us additional information as to where to find the assessment. Staff should have filed this assessment correctly and the staff on site should have looked through the service book to find the assessment. At the time of inspection Goodwill printed off the completed assessment from the Program Specialist's computer which did not have the signature or date. 09/08/2023 Implemented
SIN-00210333 Renewal 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisonous materials were not kept locked or inaccessible to individuals. There were 5 packets of Diphen, an antihistamine located in a first aid kit that was accessible to individuals.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All packets were immediately removed on August 15, 2022. 08/15/2022 Implemented
2380.181(a)Individual #1 was admitted to the facility on June 3, 2022. Individual #1 did not have an initial assessment completed within 60 days after admission to the facility.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.Assessment was completed on 8-2-2022 08/15/2022 Implemented
SIN-00191098 Renewal 08/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical on 4/6/19 and then not again until 10/21/20 exceeding the annual requirement. Individual left program on 3/16/20 due to COVID 19 and returned on 7/6/2020. The individual did not have a physical completed prior to returning to program.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #1 had a doctor appointment via phone on 6-11-20. Her doctor would not see her in person. Her group home tried to have her seen again in July but they still did not see her in person. This should have been noted in her record book and followed up before 7-6-2020. Individual #1 had her physical completed and her records are now up to date. 08/17/2021 Implemented
2380.113(c)(4)Staff # 1 had an annual physical completed on 4/23/21. Staff # 2 had a physical exam completed on 10/9/20. Staff #3 had a physical completed on 2/18/20. Staff #4 had an annual physical completed on 7/14/20. The physical exams do not include medical problems that may interfere with the health and safety of individuals.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.The physical form used at our health care provider and given to the staff if they are using their own health care provider was outdated. Goodwill's Residential Department utilized the correct form and it is now the only form utilized at Goodwill. We have several changes in the position of Vice President of Human Resources. It was believed that the form was updated at our vender but did not happen with changing staff. 08/10/2021 Implemented
2380.181(e)(4)The supervision section of Individual #4's annual assessment was not complete. Individual #4's Lifetime medical and Individual Service Plan(ISP) indicate that individual needs 1:1 staffing while at the Adult Training Facility (ATF) due to risky, impulsive tendencies. ISP also states the individual benefits from arm's length supervision and verbal reminders throughout the day at his ATF program so that he can respect the personal space of others.The assessment must include the following information: The individual's need for supervision.New Annual packages have been put together so no paperwork will be missed during the Annual ISP. The annual assessment will be completed by our Program Specialists and reviewed before each Annual ISP by the Director of CPS Services. This will ensure all information will be incuded. 08/16/2021 Implemented
2380.181(e)(14)Individual #1's assessment indicates that the individual requires verbal prompts in swimming, it does not indicate the individual's ability to swim. Individual #2's assessment indicates that the individual requires verbal prompts in swimming, it does not indicate the individual's ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.The staff believed that because Goodwill does not ever include water activities such as swimming in the curriculum that this did not have to be included. The Vice President of Mission Services explained that it must be included for everyone for unforeseen situations such as being in the community near water and an individual may slip in. This teachable moment will be included in all trainings on individual's information moving forward. 08/16/2021 Implemented
2380.21(u)Individual #1, Individual #3,Individual #4 and Individual #4 were not advised of their individual rights. Individual #1, Individual #3 and Individual #4 were advised of their rights at the time of the inspection.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.New Annual packages have been put together so no paperwork will be missed during the Annual ISP. During this meeting individual rights and the process to report a rights violation to the individual, and persons designated by the individual will be completed. 08/16/2021 Implemented
SIN-00172165 Renewal 03/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2 (DOB: 5/21/1968) had a physical exam on 11/5/2018. She didn't have another physical exam until 1/16/2020, which exceeds the annual requirement. Individual #3 was admitted on 7/17/2019. She does not have a completed physical exam in her record. Repeat Violation: 3/28/2019Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Goodwill will not render the CPS service without a current, complete physical examination. CPS Compliance Specialist will ensure a current, complete physical examination form is on file for all individuals prior to rendering service. ((CPS Compliance Specialist will review all individuals' files to ensure physical examinations are current and up-to-date. This review will occur every 3 months. Documentation of this review will be kept.-CH 4/9/20)) 03/11/2020 Implemented
2380.111(c)(5)Individual #3 (DOB: 10/13/1998) was admitted on 7/17/2019. She had a chest x-ray completed on 6/19/2019; however, she has no history of testing positive for Tuberculosis. Repeat Violation 3/28/2019The 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.CPS program has a doctor¿s note from Individual #3 primary physician. The note states ¿patient is unable to sit for tuberculin test due to phobia secondary to autism.¿ CPS Compliance Specialist will ensure that a current doctor¿s note is provided annually. 03/13/2020 Implemented
2380.111(c)(10)This section was blank on Individual #1's (DOB: 7/14/1976) physical exam dated 10/9/2019. Repeat Violation: 3/28/2019The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination form provided to the provider by individual #1 had not had this area completed. CPS Compliance Specialist will be retrained to ensure all documentation is complete and submitted in accordance with regulations.((Director of CPS Services will review all individuals' files to ensure physical examinations are current and up-to-date. This review will occur every 3 months. Documentation of this review will be kept. -CH 4/9/20)) 03/13/2020 Implemented
2380.113(a)The most current physical exam for Staff #2 is dated 5/16/2017, which exceeds therequirement. Staff #4 was hired on 2/3/2020. She does not have a physical exam in her record. Repeat Violation: 3/28/2019A 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 examination completed on 3/11/10. Staff #4 had received a physical examination on 1/21/20 prior to her start date of 2/3/20. The documentation is recorded in her employee file. CPS Compliance Specialist will be retrained to ensure all documentation is complete and submitted in accordance with regulations. ((Director of CPS Services will review staff records every 3 months to ensure physical examinations are current and contain all required information. Documentation of this review will be kept. -CH 4/9/20)) 03/11/2020 Implemented
2380.113(c)(2)The most current TB test for Staff #2 is dated 5/16/2017. Repeat Violation: 3/28/2019The 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.Staff #2 had a physical examination completed on 3/11/20. CPS Compliance Specialist will be retrained to ensure all documentation is complete and submitted in accordance with regulations. ((Director of CPS Services will review staff records every 3 months to ensure physical examinations are current and contain all required information. Documentation of this review will be kept. -CH 4/9/20)) 03/11/2020 Implemented
2380.113(c)(4)This section is not on the physical exams for Staff #1 (2/18/2020) and Staff #3 (2/24/2020).The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.Goodwill physical exam documentation has been updated to include this information. The form has been put into place and was given to the HR Department to begin using. Goodwill CPS Compliance Specialist will ensure all documentation is complete when submitted and according to requirements moving forward. All old forms have been removed from circulation. 03/13/2020 Implemented
2380.181(a)Individual #4 was admitted on 9/24/2019. He didn't have an initial assessment until 12/5/2019.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.This assessment was completed on 10-22-19. In our Foothold Awards software system the time stamping is marked with the last date it was accessed. Goodwill did not realize this was happening with the new system and will correct that with the software company. 03/12/2020 Implemented
SIN-00150996 Renewal 03/28/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1 had fire safety training on 05-01-17 and then did not complete it again until 09-10-18Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).The compliance coordinator developed new calendar process and will ensure that dates are scheduled in advance so that staff can plan to be in attendance. 04/08/2019 Implemented
2380.111(c)(5)Individual #1 had her TB test on 05/18/15, then not again until 07/28/17.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.The compliance coordinator developed new calendar process and will review physicals monthly. Program Specialists will ensure form is complete before accepting it. 04/08/2019 Implemented
2380.111(c)(7)The section pertaining to health maintenance needs was left blank on Individual #3's annual physical form.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.Physical examination forms have highlighted sections that inform physician of required information. Program Specialists will ensure form is complete before accepting it. ((The required information will be obtained from the physician. Program Specialist will be review all individual physical examinations to ensure compliance by 5/31/19 -CH 4/11/19)) 04/01/2019 Implemented
2380.111(c)(8)The section pertaining to physical limitations was left blank on Individual #2's annual physical form.The physical examination shall include: Physical limitations of the individual.Physical examination forms have highlighted sections that inform physician of required information. Program Specialists will ensure form is complete before accepting it. ((The required information will be obtained from the physician. Program Specialist will be review all individual physical examinations to ensure compliance by 5/31/19 -CH 4/11/19)) 04/01/2019 Implemented
2380.111(c)(10)The section pertaining to information pertinent to diagnosis and treatment in case of an emergency was left blank on Individual #2's and Individual #3's annual physical forms.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Physical examination forms have highlighted sections that inform physician of required information. Program Specialists will ensure form is complete before accepting it.((The required information will be obtained from the physician. Program Specialist will be review all individual physical examinations to ensure compliance by 5/31/19 -CH 4/11/19)) 04/01/2019 Implemented
2380.111(c)(11)The section pertaining to diet was left blank on Individual #2's annual physical form.The physical examination shall include: Special instructions for an individual's diet.Physical examination forms have highlighted sections that inform physician of required information. Program Specialists will ensure form is complete before accepting it. ((The required information will be obtained from the physician. Program Specialist will be review all individual physical examinations to ensure compliance by 5/31/19 -CH 4/11/19)) 04/01/2019 Implemented
2380.113(a)Staff #2's physical exam was late. She had it on 01-20-15, then not again until 05-16-17.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 compliance coordinator developed new calendar process and will review staff physicals monthly. 04/08/2019 Implemented
2380.113(c)(2)Staff #2's TB test was late. She had one completed on 01-20-15, then not again until 05-16-17.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.The compliance coordinator developed new calendar process and will review staff physicals monthly. 04/08/2019 Implemented
2380.127(a)(4)Staff #2, 3, and 4, who have been administering medications at the program, did not complete their annual recertification as required. They had no 6 month observations or MAR reviews. After initially completing their med certification trainings on 03-09-18, they did not have two observations until both occurred on 03-18-19. At that point, they were already expired. From 03-18-19 until today (03-28-19), those staff were still administering the meds.Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: A staff person who meets the criteria in §  2380.128 (relating to medication administration training), for the administration of oral, topical and eye and ear drop prescription medications and insulin injections.A new annual training plan has been developed. February and August all medication certified staff will be observed. Every March and September Goodwill will conduct MAR reviews. Five staff have since been certified to observe and two staff are being sent to receive training to become trainers. 04/11/2019 Implemented
2380.128(c)Staff #2, 3, and 4 were initially med certified on 03-09-18 and had no observations until two on 03-18-19, when they were already expired.Medications administration training of staff persons shall be conducted by an instructor who has completed and passed the Medications Administration Course for trainers and is certified by the Department to train staff persons.A new annual training plan has been developed. February and August all medication certified staff will be observed. Every March and September Goodwill will conduct MAR reviews. Five staff have since been certified to observe and two staff are being sent to receive training to become trainers. 04/11/2019 Implemented
2380.128(d)There was no Annual Practicum training sheet in Staff 2, 3, or 4's files indicating that they were recertified as med trained staff.A staff person who administers prescription medications or insulin injections to individuals shall complete the Medications Administration Course Practicum annually.A new annual training plan has been developed. February and August all medication certified staff will be observed. Every March and September Goodwill will conduct MAR reviews. Five staff have since been certified to observe and two staff are being sent to receive training to become trainers. 04/11/2019 Implemented
SIN-00132447 Renewal 03/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical exam on 12/29/2016. She hasn't had another physical exam since then, which exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Goodwill has hired a new employee in this department to monitor compliance of staff and individuals served. Physical forms are being sent home when individuals are due for physicals with a note addressing all areas that need to be completed. This new staff person will ensure forms are returned to meet compliance or contact each guardian. ((Individual #1 will immediately receive an annual physical examination -CH 6/12/2018)) 03/29/2018 Implemented
2380.111(c)(3)There's no record of required immunizations on the physical exams for Individual #1 (12/29/2016) and Individual #3 (8/18/2017).The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Goodwill has hired a new employee in this department to monitor compliance of staff and individuals served. Physical forms are being sent home when individuals are due for physicals with a note addressing immunization record dates. This new staff person will ensure forms are returned to meet compliance or contact each guardian. ((Missing information will be requested from Individual #1's and Individual #3's physicians -CH 6/12/20187)) 04/12/2018 Implemented
2380.111(c)(4)This area wasn't filled in on Individual #3's physical exam dated 8/18/2017.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Goodwill has hired a new employee in this department to monitor compliance of staff and individuals served. Physical forms are being sent home when individuals are due for physicals with a note addressing all areas that need to be completed. This new staff person will ensure forms are returned to meet compliance or contact each guardian. ((Missing information will be requested from Individual #3's physician -CH 6/12/2018)) 03/29/2018 Implemented
2380.111(c)(8)This area wasn't filled in on Individual #3's physical exam dated 8/18/2017.The physical examination shall include: Physical limitations of the individual.Goodwill has hired a new employee in this department to monitor compliance of staff and individuals served. Physical forms are being sent home when individuals are due for physicals with a note addressing all areas that need to be completed. This new staff person will ensure forms are returned to meet compliance or contact each guardian. ((Missing information will be requested from Individual #3's physician -CH 6/12/2018)) 03/29/2018 Implemented
2380.111(c)(10)This area wasn't filled in on Individual #3's physical exam dated 8/18/2017.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Goodwill has hired a new employee in this department to monitor compliance of staff and individuals served. Physical forms are being sent home when individuals are due for physicals with a note addressing all areas that need to be completed. This new staff person will ensure forms are returned to meet compliance or contact each guardian. ((Missing information will be requested from Individual #3's physician -CH 6/12/2018)) 03/29/2018 Implemented
2380.111(c)(11)This area wasn't filled in on Individual #3's physical exam dated 8/18/2017.The physical examination shall include: Special instructions for an individual's diet.Goodwill has hired a new employee in this department to monitor compliance of staff and individuals served. Physical forms are being sent home when individuals are due for physicals with a note addressing all areas that need to be completed. This new staff person will ensure forms are returned to meet compliance or contact each guardian. ((Missing information will be requested from Individual #3's physician -CH 6/12/2018)) 03/29/2018 Implemented
2380.113(a)Staff #2 had a physical exam on 5/16/2017. Her previous physical exam wasn't in her record. Staff #3 had a physical exam on 6/8/2015. He didn't have another physical exam until 3/29/2018, which exceeds the 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.All employee record have been reviewed and updated to meet requirements. Goodwill has also hired a new employee in this department to monitor and track all employee records and due dates to meet complience. 03/29/2018 Implemented
2380.113(c)(2)Staff #2 had a TB test on 5/16/2017. Her previous TB test wasn't in her record. Staff #3 had a TB test on 6/8/2015. As of 3/29/2018, he didn't have another TB test, which exceeds the requirement.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 employee record have been reviewed and updated to meet requirements. Goodwill has also hired a new employee in this department to monitor and track all employee records and due dates to meet complience. 03/29/2018 Implemented
2380.113(c)(3)The physical exams for Staff #1, Staff#2, Staff #3, and Staff #4 do not have signed statements saying they are free from 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.Goodwill Human Resource Department has changed medical vendors to meet requirement to always be in compliance. Previous vendor refused to properly document signed statements. ((Missing information will be requested for Staff #1, Staff #2, Staff #3, and Staff #4 -CH 6/12/2018)) 03/30/2018 Implemented
2380.181(a)Individual #3's annual assessment dated 6/2/2017 was not complete because the progress and growth over the last 365 calendar days for the following areas: Health, motor/communication skills, activities of residential living, personal adjustment, socialization, recreation, and community integration.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.Individual #3¿s assessment were corrected on March 29, 2018. To avoid non-compliance in the future assessments will be monitored by Compliance Specialist on a monthly basis. 03/29/2018 Implemented
2380.181(e)(12)There were no recommendations for specific areas of training, programming and services in the assessments for Individual #1 (10/25/2017), Individual #2 (7/6/2017), Individual #3 (6/2/2017), and Individual #4 (10/13/2017).The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Staff has been retrained on assessments and tracking of individual's goals and progress to meet goals. Staff has also been trained on ODP CPS and Everyday Lives to better give recommendations. 04/02/2018 Implemented
SIN-00111958 Renewal 05/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62There were no emergency numbers posted as required.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.Program specialist relocated emergency numbers to wall closest to telephone. 05/23/2017 Implemented
2380.83(b)Diagrams of the facility were posted, but they were all blank with no information regarding evacuation routes.An evacuation diagram shall be posted in all areas of the facility.Evacuation diagrams were updated by program specialist to include emergency exit routes. 05/24/2017 Implemented
2380.111(c)(3)Individual #3's physical form had no information on Immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which contains the required immunization information. ((Family has requested a copy of immunizations from the physician's office -CH 8/3/17)) 05/24/2017 Implemented
2380.111(c)(5)There was no evidence of TB tests being completed in Individual #2's or Individual #3's files.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.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which documents TB testing. ((Individual #2 has an appointment with his physician in August to have Mantoux completed. Individual #3's family is contacting the physician for this information. - CH 8/3/17)) 05/24/2017 Implemented
2380.111(c)(6)Communicable diseases were not addressed on the physical forms of Individuals #2 and #3.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.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which provides a space for the physician to document communicable diseases and the specific precautions that should be taken. ((the families of Individual #3 and Individual #3 are contacting the physicians to get this information - CH 8/3/17)) 05/24/2017 Implemented
2380.111(c)(7)Health maintenance needs were not addressed on the physicals of Individuals #2 and #4.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.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which provides a space for the physician to document health maintenance needs. ((Individual #2 and Individual #4 have been given new physical forms to be filled out by their physicians - CH 8/3/17)) 05/24/2017 Implemented
2380.111(c)(8)Physical limitations were not addressed on the physicals of Individuals #2 and #3.The physical examination shall include: Physical limitations of the individual.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which provides a space for the physician to document physical limitations. ((Individual #2 and #3 have been given new physical forms to have completed by their physicians - CH 8/3/17)) 05/24/2017 Implemented
2380.111(c)(9)Allergies were not addressed on Individual #2's physical form.The physical examination shall include: Allergies or contraindicated medication.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which provides a space for the physician to document allergies and/or contraindicated medication. ((Individual #2 has an appointment with his physician in August to get this information - CH 8/3/17)) 05/24/2017 Implemented
2380.111(c)(10)The section regarding info pertinent to diagnosis and treatment in case of emergency was not on the physicals of Individuals #2 and #3 and left blank on the physical of Individual #4.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which provides a space for the physician to document information pertinent to diagnosis and treatment in case of an emergency. 05/24/2017 Implemented
2380.111(c)(11)Dietary needs were not addressed on the physical forms of Individuals #2 and #4.The physical examination shall include: Special instructions for an individual's diet.All individuals will be required to submit the Physical Exam form provided by Goodwill Industries of NEPA, which provides a space for the physician to document special instructions for an individual's diet. ((Individual #2 and #4 have appointments with their physicians in August to complete this information - CH 8/3/17)) 05/24/2017 Implemented
2380.173(1)(iii)Information regarding communication/primary language was missing from all four of the Individual files reviewed.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.Primary language line added to individual face sheets. 05/24/2017 Implemented
2380.181(f)There was no documentation in any of the four files reviewed that the assessments are sent to team members at least 30 days prior to the ISP meeting, 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 will file a copy of the dated letter attached to the assessment in individual's file. 07/03/2017 Implemented
SIN-00093087 Renewal 04/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual 2 had a Tuberculin skin test on 6/20/2011 and not again until 11/16/2015.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.Goodwill Industries of NEPA has implemented a new Annual Physical Form that needs to be completed and returned to our program by the Physician. This new form contains highlighted areas that must be completed including Last Date of Tuberculin Skin Test. This form also noted that the test must be completed within two years of current exam date. Staff must review this form when return to ensure all areas are completed and current. 06/30/2016 Implemented
2380.173(1)(ii)Three of the four individual records reviewed did not contain the regulated personal information. Individuals #1 and #3 had a record did not contain hair color, eye color, or identifying marks. Identifying marks was left blank on individual #2¿s record. 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.Goodwill Industries of NEPA has implemented a new cover sheet for each clients record. This cover sheet contains the regulated personal information including Personal information, race, height, weight, color of hair, color of eyes and identifying marks. All records will contain this new document. 06/01/2016 Implemented
2380.173(1)(iv)Three of the four individual records reviewed did not contain the regulated personal information. Individual 1, 2, and 3 had a record that did not contain the religious affiliation. Each individual¿s record must include the following information: Personal information including: Religious affiliation.Goodwill Industries of NEPA has implemented a new cover sheet for each clients record. This cover sheet contains the regulated personal information including Personal information and religious affiliation. All records will contain this new document. 06/01/2016 Implemented
2380.173(1)(v)Three of the four individual records reviewed did not contain a current dated photo of the individual. Individual #1, #3, and #4 had a photo that was undated. Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Goodwill Industries of NEPA has implemented a new cover sheet for each clients record. This cover sheet contains the regulated personal information including Personal information and Date of most recent photo. All records will contain this new document. 06/01/2016 Implemented
2380.173(9)Individual #4¿s ISP states that she is safe with poisons, however her annual assessment dated 7/23/2015 states that she is unsafe with poisons. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Goodwill Industries of NEPA has updated our Annual Assessment Form for clearity and ease of use. We are currently re-training staff on Annual Assessments and discrepancies with the ISP and process for update and revision. 06/30/2016 Implemented
SIN-00073897 Renewal 02/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)Individual #3 is deaf and would not be alerted in the event of a fire in two specific areas of the Program. An office was recently converted into a First Aid room and there is no adaptations to alert Individual #3 in the event of a fire. Also divider walls were removed from a large room where programming takes place and there are no adaptations to alert Individual #3 in the event of a fire. If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.Goodwill Industries has ordered 2 additional smoke detectors with strobe lights. The strobe lights were installed and tested on 3/2/2015. 03/20/2015 Implemented
2380.91(a)Individual #2 was admitted into the Goodwill Day Program in August of 2014 and did not receive fire safety training until 10/01/2014.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.Goodwill Industries will conduct fire safety training for individuals upon admission. A program Specialist has been assigned the task of ensuring that this happens. A 2nd Program Specialist will review fire safety records on a quarterly basis to ensure that this training requirement is met. Additionally, consumers and staff receive fire safety training on an annual basis 02/20/2015 Implemented
2380.111(a)Individual #2 was admitted to the Goodwill Day Program in August of 2014 and as of 02/18/2015 he still does not have a physical examination on file.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialists will thoroughly review a consumers file prior to admittance to ensure completeness. Additionally,we will have developed a spreadsheet listing each consumer and the date they were admitted to the program. Program Specialists will review this document on a monthly basis to determine when a consumers annual physical is needed.Consumers will be given 6-8 weeks advance notice as to their need for a physical. Individual #2's family has been informed of the need for an annual physical examination and Goodwill Industries is waiting on an appointment date. 03/13/2015 Implemented
2380.111(c)(5)There was no record of Individual #1 and #2 have a tuberculin skin test.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 aforementioned spreadsheet will also include information pertaining to Tuberculin testing. Records will be reviewed prior to admittance to ensure that the results of a TB test are included. As in the case of the annual physical, consumers will be given 6-8 weeks notice regarding the need for a Tuberculin Test. Both Individual #1 and Individual #2 have had updated TB skin tests with negative results. 03/13/2015 Implemented
SIN-00059800 Renewal 02/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)According to training records the staff #1 only had 19 hours of training during the calendar year of 2013. (b)  The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Upon further review, it was determined that several areas of training were omitted from the listing. In order to avoid this in the future, the training list will be reviewed on a monthly basis. A revised listing has been submitted to the Licensing Inspector. 02/19/2014 Implemented
2380.53(a)One container of Germ X hand sanitizer was sitting on a table in the program room and one container of Great Value dish detergent was under the kitchen sink and another was on the counter top. All containers were unlocked and accessible to the consumers at the Day Program. All containers had a warning label with instructions to contact the poison control center and physician immediately if swallowed.(a)  Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Staff were given additional Instruction regarding the importance of keeping chemicals in a secure location. Additionally, efforts will be made to purchase all-natural,non-chemical products. Poisons were locked at the time of inspection on 02/04/2014 as witnessed by me-Rich Saikowski Licensing Representative. 02/12/2014 Implemented
2380.82One exit door has an inside lock which requires the use of a removable key to operate. This type of lock is prohibited.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.A locksmith was called immediately after the inspection. Repairs have been made. 03/10/2014 Implemented
2380.87(b)Individual #1 is deaf and there is no strobe light connected to the fire alarm system that would alert him while he is in the bathroom.(b)  If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.An additional strobe light was ordered on2/6/14.Unit will be installed on 2/21/14.A new hardwired system was installed and validated on 03/06/2014 by the Licensing Representative. 02/21/2014 Implemented
2380.89(e)According to fire drill records there was no documentation indicating that alternate exit routes were used during fire drills.(e)  Alternate exit routes shall be used during fire drills.Fire safety plan was modified to include alternate routes.The rt. used will be listed on fire drill log. 02/14/2014 Implemented
2380.184(a)ISP signature pages for Individual #1 and Individual #2 did not show that the Program Specialist or a qualified Representative from Goodwill Industries, Inc. attended the ISP meetings. (a)  The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision).A Goodwill Staff member is scheduled to attend all ISP meetings. We will include a back-up staff person on the schedule in the event that one of our staff is unable to attend. 02/18/2014 Implemented
SIN-00047916 Initial review 04/22/2013 Compliant - Finalized