| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.84 | No fire safety inspection was provided to licensing upon inspection. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | Johnson Controls completed the fire safety inspection on 1/7/2022. The fire saftey inspection report is on file. |
01/07/2022
| Implemented |
| 2380.111(a) | REPEAT VIOLATION- 9/8/15, 12/28/17, 9/26/19(Previous Inspection)
Individual #2 was admitted into the program on 8/3/20. Initial/admittance physical exam submitted for review had a 'Date of Exam" date of 06/26/2019. Physician signed this physical on 11/11/2019. No other physicals were completed. Physical examinations shall be completed within 12 months prior to admission and annually thereafter. Additional items noted to be missing from the admittance physical exam are as follows: 111c3-Immunizations, 111c4-vision & hearing screening, 111c5- TB test not current, date provided 4/28/17, 111c6- communicable disease. Annual physical encompassing all areas is required.
*Note 111c3- violations on 11/17/16 and 9/26/19
111c5- violations on 9/8/15 and 9/21/18. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2 completed the required physical exam on 8/12/2021. The physical form is on file. |
01/13/2022
| Implemented |
| 2380.111(c)(5) | Individual #1 had a physical dated 11/3/2021 which did not have the TB results attached. Unknown when a TB test or chest xray was completed and what the results of that test was. Repeat violation from inspections occurring on 9/8/2015 and 9/21/2018 | 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. | A chest X-ray for Individual #1 was completed 5/13/2016 which was noted on her physical form dated 5/18/2018. Program Director was informed that this notation on previous physical was no longer acceptable documentation and therefore, Program Director has requested separate documentation from the individual's guardian/caregiver. |
03/20/2022
| Implemented |
| 2380.113(a) | Staff #1 had a physical exam completed on 9/25/2018 and there was no follow up physical on file, this exceeds the requirement of every 2 years.
REPEAT VIOLATION from 9/26/2019(previous inspection) | 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 #1 physical exam was completed on 1/12/2022 and is on file. |
01/12/2022
| Implemented |
| 2380.113(c)(2) | Staff #1 had TB testing completed on 9/28/2018 and there was no follow up test provided. This exceeds the 2-year requirement. REPEAT VIOLATION from 9/26/2019(previous inspection) | 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 TB test was administered on 1/12/2022 and read on 1/14/2022 the results are on file. |
01/14/2022
| Implemented |
| 2380.181(a) | Individual #1 did not have an updated assessment for the year 2021. The program reopened in July 2021 and has been open through December 2021 from Covid.
Individual #2 was admitted into the program on 8/3/20. Initial assessment was completed on 10/4/20. An updated annual assessment was not completed for 2021. The 10/4/20 assessment submitted for review was lacking many of the required items. The following items/areas were not found in the 10/4/20 assessment:
181c-Based on instruments, interviews, notes and observations, 181d-PS sign and date assessment, 181e1-Needs and preferences, 181e9-Disability, functional and medical limitations, 181e10-Lifetime medical history, 181e12-Recomendations, 181e13i-Health, 181e13ii-Motor, 181e13vi- Community integration, 181(14)- Knowledge of water safety/ability to swim and 181f-Provide documentation to SC & team 30 days prior to Individual Support Plan (ISP) meeting. Annual update of all assessment items is required.
*Note 181e13ii violation on 12/28/17 181f violation on 12/28/17 | 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 #1 assessment for the year 2021 has been completed and is on file. |
01/20/2022
| Implemented |
| 2380.21(u) | No documentation was provided to indicate that individual rights had been reviewed with Individual #1 or Individual #2. A review of individual rights must occur upon admission and annually thereafter. | 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. | The individual rights have been reviewed with Individual #1 and Individual #2 on 1/13/2022. |
01/13/2022
| Implemented |
| 2380.36(b) | Staff #1 serves as the CEO and Program Specialist. There was no documentation that an annual fire safety training had occurred during 2021.
Staff #2 had an initial fire safety training on 10/21/20. There was no documentation that an annual fire safety training had occurred during 2021. As of 1/4/22 there was no documentation of annual fire safety training being completed. REPEAT VIOLATION from 9/26/2019(previous inspection) | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The Program Specialist completed the YAI Fire Safety Course on 1/13/2022. The documentation is on file. |
01/13/2022
| Implemented |
| 2380.38(b)(1) | Staff #2 was hired on 10/23/20. There was no documentation to support that Staff #2 received training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships as required prior to working alone with individuals, and within 30 days after hire. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #2 received and completed the training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 1/13/2022. Record has been updated and is on file. |
01/13/2022
| Implemented |
| 2380.38(b)(2) | Staff #2 was hired on 10/23/20. There was no documentation to support that Staff #2 received training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act as required prior to working alone with individuals, and within 30 days after hire. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff #2 received and completed the training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act on 1/13/2022. Record documentation has been updated and is on file. |
01/13/2022
| Implemented |
| 2380.38(b)(3) | Staff #2 was hired on 10/23/20. There was no documentation to support that Staff #2 received training on Individual rights as required prior to working alone with individuals, and within 30 days after hire. | The orientation must encompass the following areas: Individual rights. | Staff #2 received and completed the training Individual rights on 1/13/2022. Record has been updated and is on file. |
01/13/2022
| Implemented |
| 2380.38(b)(4) | Staff #2 was hired on 10/23/20. There was no documentation to support that Staff #2 received training on recognizing and reporting incidents prior to working alone with individuals, and within 30 days after hire as required. | The orientation must encompass the following areas: Recognizing and reporting incident. | Staff #2 received and completed training on recognizing and reporting incidents on 1/13/2022. |
01/13/2022
| Implemented |
| 2380.39(b)(1) | Staff #1 did not have 12 hours of annual training. | The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | Staff #1 will complete the remaining 3 hours of the 12 hours required training each year, by 3/20/2022. |
03/20/2022
| Implemented |
| 2380.39(c)(1) | Staff #1 and Staff #2 did not have annual training in the area of application person center practices, community integration, individual choice, supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #1 and Staff #2 completed the annual training in the area of application person centered practices, community integration, individual choice, supporting individuals to develop and maintain relationships on 1/20/2022 |
01/20/2022
| Implemented |
| 2380.39(c)(2) | Staff #1 and staff #2 did not have annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff #1 and staff #2 received and completed the training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 1/20/2022. |
01/20/2022
| Implemented |
| 2380.39(c)(3) | Staff #1 and Staff #2 did not have annual training of individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #1 and staff #2 received and completed the training of individual rights on 1/20/2022. |
01/20/2022
| Implemented |
| 2380.39(c)(4) | There was no documentation to support that Staff #1 or #2 received annual training on recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff #1 and staff #2 received and completed the training on recognizing and reporting incidents on 1/20/2022. |
01/20/2022
| Implemented |
| 2380.39(c)(5) | Staff #1 and staff #2 did not have annual training in safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff #1 and staff #2 received and completed the training in safe and appropriate use of behavior supports on 1/20/2022. |
01/20/2022
| Implemented |
| 2380.39(c)(6) | Staff #1 and staff #2 did not have annual training in 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 staff #2 received and completed the training on implementation of the individual plan (ISP) on 1/27/2022. |
01/27/2022
| Implemented |