Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225137 Renewal 07/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #1 date of hire was 2/27/23. Staff #1 had a PA criminal history submitted on 2/5/2023. The results reflect that the request is still pending for control. The agency did not have a current PA criminal record check on file at the time of inspection.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.The staff member was able to access the PATCH System on the night of the inspection and print out the Clearance, which was no longer pending, and contained the request date of 2/5/2023. Staff # 1's date of hire was 2/27/23. At the time of inspection, attempts to access the clearance website were unsuccessful. (See attached) An update was made to the Policy for screening new employees, since there is a multistep process involving our 'parent company', the Diocese of Allentown. New hires are required to complete an extensive checklist in which some items differ from what is required by the 2380 regulations. Once clearances are received, they are forwarded to the Diocese, who performs the final check of the clearances and requirements. If pending, an employee would not be allowed to start. When the clearance was no longer 'pending', the Diocese does not forward the paper copy, but send their own checklist to indicate a person can begin employment, so our site never receives the final clearance. To remedy this issue, the John Paul II Center Safe Environment Coordinator, whose role is to gather and forward all the items on the checklist, will ensure all the record checks have been cleared and a copy forwarded to the Adult Program prior to sending items to the Diocese of Allentown. All requests will be checked for clearance and any pending requests will be noted for follow-up prior to employee start date. 08/03/2023 Implemented
SIN-00207183 Renewal 07/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.39(c)(1)There was no documentation to support that training on community integration and supporting individuals to develop and maintain relationships was conducted for Staff #3 and Staff #4. Training on all stated areas is required to fully satisfy the regulatory requirements.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.Although the documentation was not available at inspection for staff #3 & #4 they in fact were present at the meetings and have since signed the attendance. The system of recording trainings did not adequately provide topic/contents of training. As per our Q A & I plan a new system had been developed for staff training and tracking. This has been addressed and changes to training documentation made. 08/01/2022 Implemented
SIN-00189187 Renewal 07/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #7 was hired on 6/14/2021. A Criminal History Check was not completed until 7/15/2021, exceeding the 5-day requirement.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.Staff #7 has been employed with John Paul II since 08/08/2008 in the school age Program. (JPII Center has two programs: adult program and school age program). The clearances viewed at the inspection were the 5 year updates. Attached please find the former clearances dated 01/21/2016. The absence of both start dates provided confusion and points to an operational gap when school program staff are shared with the adult program. 07/30/2021 Implemented
2380.53(a)A container of Ajax powder cleanser was found under the sink in the kitchen are. The label on this container states: "Seek medical attention if ingested."Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The container of Ajax was discarded. Poisons from 2380.53(a-c) has been added to the staff training policy and will be reviewed on an annual basis or more frequently as needed. 07/28/2021 Implemented
2380.111(c)(10)This section was blank on Individual #1's (DOB: 10/13/1998) physical exam dated 6/14/2021.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Although 2380.111(c)(10) is included on the physical, it is at times not completed by the physician. To address this, a letter is sent with the physical requesting this area needs to be filled in and the box has been highlighted. If an incomplete physical is returned to program the Healthcare Coordinator immediately contacts the physician's office. At times the office may not respond or does so in an untimely manner. Many times, the Healthcare Coordinator must make numerous requests for the physical form completion and enlist the assistance of the participant or family member. Going forward all attempts to have forms completed will be documented on a progress note in the medical section of the client file to indicate attempts to have the form completed. 08/06/2021 Implemented
2380.113(a)Staff #7 was hired on 6/14/2021. She currently does not have a physical exam.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 #7 had a physical in January 2021 but did not have the form completed (as it is not required in the school program, where she was working at the time of the physical). Staff #7 has an appointment to have the form completed on 08/06/2021. The inspection points to an operational gap when school program staff are shared with the adult program. Program Director and CEO will develop a checklist to ensure all requirements are met for staff who work in both the school and adult program. since requirements differ. This will be in place on or before Sept. 1, 2021 and will be used prior to school staff starting in the adult program. 08/12/2021 Implemented
2380.113(c)(2)Staff #7 was hired on 6/14/2021. She currently does not have a physical exam.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 #7 did not have a completed PPD. Staff #7 expects this to be completed on or before 08/13/2021. The inspection points to an operational gap when school program staff are shared with the adult program. Program Director and CEO will develop a checklist to ensure all requirements are met for staff who work in both the school and adult programs since requirements differ. This will be in place on or before Sept.1, 2021 and will be used prior to school staff starting in the adult program. 09/01/2021 Implemented
2380.113(c)(4)This section was missing on the physical exams for Staff #2, Staff #3, Staff #4, Staff #5 and Staff #6.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.A section was added to the staff physical which requests information of medical problems which might interfere with the safety of health of the individual. 07/29/2021 Implemented
2380.173(1)(ii)Hair and eye color and identifying marks were not listed in the record for Individual #1.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.Hair and eye color and identifying marks are included on the face sheet in each individual record. The face sheet is typically completed and in the client's file within the first week in program. Individual #1 started program virtually in Fall 2020 due to COVID-19. Face sheet had not been printed and filed in the record. Upon request for information, the face sheet could not be produced, due to computer system conversion the week prior to inspection and resulting in the inability to access the database. The face sheet was printed and filed in the record on 07/29/21. 07/29/2021 Implemented
2380.173(1)(iv)Religious affiliation was not listed in the record for Individual #1.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Religious affiliation is included on the face sheet in each individual record. The face sheet is typically completed and in the client file within the first week in program. Individual #1 started program virtually in Fall 2020 due to COVID-19. Face sheet had not been printed and filed in record. Upon request for information the face sheet could not be produced due to computer system conversion the week prior to inspection and resulting in the inability to access the database. The face sheet was printed and filed in the record on 07/29/2021. 07/29/2021 Implemented
2380.173(1)(v)A current, dated photograph was not in the record for Individual #1.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.A photograph of individual #1 is included on the face sheet in each individual record. The face sheet is typically completed and in the client file within the first week in program. Individual #1 started program virtually in Fall 2020 due to COVID-19. Face sheet had not been printed and filed in record. Upon request for information the face sheet could not be produced due to computer system conversion the week prior to inspection and resulting in the inability to access the database. 07/29/2021 Implemented
2380.21(u)Individuals in this program have all been informed of their rights. However, the Individual Rights have not been fully updated to reflect the new Chapter 2380 regulations. The missing Individual Rights include: An individual may not be reprimanded, punished or retaliated against for exercising the individual's rights; An individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual; and to accept risks.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.Rights and Responsibilities have been updated to reflect all areas outlined in 6100 and 2380 regulations. The sections were labeled with the corresponding chapter subsections. 08/03/2021 Implemented
2380.36(b)Staff #6 most current fire safety training is dated 11/21/2019. This program has been reopened since 7/14/2021.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Due to COVID-19 closures and furlough of staff the fire and safety training for staff #6 was not completed in Oct. 2020 due to her absence from program. The fire safety training has been completed on 08/06/2021 for this employee. Program specialists are responsible to ensure all required annual trainings are completed and documented. 08/06/2021 Implemented
2380.38(b)(1)Orientation for Staff #4 and Staff #7 did not include the application of person-centered practices, individual choice and supporting individuals to develop and maintain relationships.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 #4 and #7 did receive the stated trainings in person ( see orientation curriculum) and through the CPS on-line 3-hour training on MyODP. Through the inspection it was clear that the method of documentation of trainings did not clearly indicate what training was given. The Program Director and administrative assistant will review and revise how the documentation is currently handled and develop a process which will better reflect the completion of the required areas. This process will be in place on or before Oct. 1, 2021 10/01/2021 Implemented
2380.39(c)(1)Annual training for Staff #2, Staff #3, Staff #5 and Staff #6 did not include the application of person-centered practices, individual choice and 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 #2,3,5,6 did in fact receive the training areas included in 2380(b)(1). Through the inspection it was clear that the method of documentation of trainings did not clearly indicate what training was given. The Program Director and administrative assistant will review and revise how the documentation is currently handled and developed a process which will better reflect the completion of the required areas. This process will be in place on or before Oct. 1, 2021. 10/01/2021 Implemented
2380.126(a)(11)Individual #2 is administered Losartan (50mg) and Verapramil ER (240mg) at noon while in program. Her Medication Administration Record (MAR) does not have the diagnosis or purpose for these medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Although the diagnosis was included at the bottom of the Medication Administration form, the diagnosis for each medication was also added to each medication box to reflect the purpose of the medication. 07/29/2021 Implemented
SIN-00153968 Renewal 04/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)The annual physical examination dated 9/19/18 for Individual #1 did not contain information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The current physical form is send with a letter stating all areas must be completed. Upon receiving the physical the Healthcare Coordinator checks that areas are completed and contacts the physician requesting that anything missing is added. The Healthcare Coordinator will document all efforts to have physical fully completed. The Healthcare Coordinator, Director and Program Specialists are reviewing the physical form to determine if some areas can be pre-populated to assist in full form completion by healthcare providers. Any areas which can be prepopulated or made easier for the doctor to complete will be completed by July 1, 2019 and any physicals sent out following that date will contain the changes. ((The physician for Individual #1 will be contacted to obtain the missing information -CH 5/31/19)) 07/01/2019 Implemented
2380.181(a)The annual assessment for Individual #1 was completed late. The current annual assessment was completed on 3/11/19 and the previous assessment was completed on 2/18/18. The annual assessment for Individual #3 was completed late. The current annual assessment was completed on 12/10/18 and the previous assessment was completed on 10/10/17.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.A new list will be developed specifically for Assessments that will include the completion and distribution dates. This list will be maintained by the Program Specialist, who is also responsible for the completion and sending of the assessment. The completion date will not exceed 60 days from the start of program and/or more than one calendar year from the last Assessment date. 09/02/2019 Implemented
2380.181(f)The annual assessment dated 3/11/19 for Individual #1 was not sent to the SC and plan team members at least 30 calendar days prior to the ISP meeting scheduled for 4/11/19, and later rescheduled to 4/23/19. The annual assessment dated 2/01/19 for Individual #2 was not sent to the SC and plan team members at least 30 calendar days prior to the ISP meeting scheduled for 2/07/19.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).There currently is a checklist which states the due dates for Quarterlies, Assessments and LTM which were traditionally completed at the third Quarterly, which provided ample time to comply with the 30 day requirement. However in the past year many ISP meetings have been scheduled for the third Quarterly, so the assessment needs to be completed earlier. A new list will be developed specifically for Assessments that will include the completion and distribution dates. This list will be maintained by the Program Specialist, who is also responsible for the completion and sending of the assessment. 09/02/2019 Implemented
SIN-00132367 Renewal 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The last annual fire safety inspection was in January of 2017The 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.A firesafety inspection has been completed. A yearly reminder will be set up to have the inspection done. 05/01/2018 Implemented
2380.111(c)(1)The medical history section on Individual #1's physical form was left blank.The physical examination shall include: A review of previous medical history.A letter was written to the physician asking them to fill in this section which was faxed to the office. We are adding a note to each physical form sent to physicians asking them to fill out the entire form. 05/31/2018 Implemented
2380.111(c)(3)Individual #1's TDaP immunization was late. Her DOA was 08-21-17 and she did not receive it until 09-11-17.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Immunization history will be checked before admission to program. If there is evidence that the immunization was not completed as per state & federal regulations admission to program will be delayed until the immunization is completed & results are forwarded to program. 05/01/2018 Implemented
2380.111(c)(5)Individual #1's TB test was late. Her DOA was 08-21-17 and she had it 09/11/17.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.Immunization history will be checked before admission to program. If there is evidence that the immunization was not completed as per state & federal regulations admission to program will be delayed until the immunization is completed & results are forwarded to program. 05/01/2018 Implemented
2380.111(c)(9)The allergies section on Individual #1's physical form was left blank.The physical examination shall include: Allergies or contraindicated medication.A letter was written to the physician about needing to fill in all sections of the physical form. We are adding a note to each physical form sent to the physicians asking them to fill out the entire form. 05/31/2018 Implemented
2380.111(c)(10)The section regarding information pertinent to diagnosis and treatment in case of emergency was left blank on Individual #1's physical.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.We are in the process of adding the above information to our physical form paperwork. 07/30/2018 Implemented
2380.181(a)Individual #3's initial assessment was not completed within 60 days after her date of admission. It was completed at 90 days.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.A change was made to protocol, where the initial assessment will be completed within 1 yr. prior to admission or within 60 days of admission. ((Program Specialist will be trained on this new protocol -CH 5/24/2018)) 05/18/2018 Implemented
2380.181(e)(3)(i)The section in Individual #1's and Individual #2's assessments pertaining to current level and performance in the area of acquisition of functional skills was not present.The assessment must include the following information: The individual's current level of performance and progress in the following areas:  Acquisition of functional skills.As there were multiple versions of the assessment some did not contain this section. It has been reviewed and the appropriate assessment saved while all other versions have been deleted. ((Program Specialist will be trained on the requirements of this regulation and in the use of the proper assessment form. Program Specialist will review all assessments and update all assessments by 8/31/2018 -CH 5/24/2018)) 06/01/2018 Implemented
2380.181(e)(3)(ii)The section in Individual #1's and Individual #2's assessments pertaining to current level and performance in the area of communication was not present.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Communication.As there were multiple versions of the assessment some did not contain this section. It has been reviewed and the appropriate assessment saved while all other versions have been deleted. ((Program Specialist will be trained on the requirements of this regulation and in the use of the proper assessment form. Program Specialist will review all assessments and update all assessments by 8/31/2018 -CH 5/24/2018)) 06/01/2018 Implemented
2380.181(e)(3)(iii)The section in Individual #1's and Individual #2's assessments pertaining to current level and performance in the area of personal adjustment was not present.The assessment must include the following information: The individual's current level of performance and progress in the following areas:  Personal adjustment.As there were multiple versions of the assessment some did not contain this section. It has been reviewed and the appropriate assessment saved while all other versions have been deleted. ((Program Specialist will be trained on the requirements of this regulation and in the use of the proper assessment form. Program Specialist will review all assessments and update all assessments by 8/31/2018 -CH 5/24/2018)) 06/01/2018 Implemented
2380.181(e)(10)There was no lifetime medical history included in the assessments in any of the four files reviewed.The assessment must include the following information: A lifetime medical history.The lifetime medicals were located in another section of the book. The sections have been put next to one another and the LTM is attached to the assessment when it is sent prior to the ISP meeting. 07/02/2018 Implemented
2380.184(c)The meeting participants and signatures for the 2018 ISP meetings already held were not in Individual #1's or Individual #2's files.A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet.Obtain copies of Support Coordinator's ISP sign in sheets prior to the end of the meeting 05/18/2018 Implemented
2380.186(a)The last ISP quarterly review was completed for Individual #2 on 12/23/15.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP.Past due quarterlies have been completed. Program Specialist must make regular use of tracking system which outlines when quarterlies are due. 05/18/2018 Implemented
SIN-00111935 Renewal 04/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(g)It is not documented that individuals have evacuated to the meeting place.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.A check off box indicating if participants evacuated to the designated meeting place has been added to the fire drill log. There is a section to note any problems if individuals do not go to the designated meeting place and a section where solutions to any problems should be noted. 05/15/2017 Implemented
2380.89(h)It has not been documented that fire alarms are being set off during fire drills this past year.A fire alarm shall be set off during each fire drill.A check off box has been added to the fire drill log indicating whether the alarm system was activated at the time of the drill. If it isn¿t, the reason will be noted in the section which notes if there are problems during the drill. Follow-up will be noted in the next section as needed. 05/15/2017 Implemented
2380.91(a)Individual #1 was admitted to program on 3/16/2017. She didn't receive initial fire safety training until 3/17/2017. Individual #2 was admitted to program on 11/22/2016. He didn't receive initial fire safety training until 11/29/2016. (Repeat violation: 4/7/2016)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.Fire safety and evacuation routes will be reviewed with all future admissions on the first day in program, rather than within the first week, as was the practice. Fire Safety was added to the `New Participant Checklist¿. 04/27/2017 Implemented
2380.111(c)(5)Individual #4 had a TB test on 1/6/2015. He didn't have another TB test until 1/30/2017, 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 positvie, an initial chest X-ray with results noted.Provider sends out a physical letter and the physical form two months prior to when it is due. The letter states if TB or tetanus are due. In this case the PPD was not completed during the physical. When it was received the parent was informed it needed to be completed and they made an appointment. Staff mistakenly counted 10 days from the new physical, rather than the old PPD date. Corrective Action: Program Specialists and Direct Care Supervisor reviewed regulations and will insure that anyone not receiving the PPD within the 10 day grace period from the previous test will be suspended, as is our practice. Also, the PPD and tetanus section of the physical will be highlighted to remind the doctor at the time of the physical. 05/15/2017 Implemented
2380.111(c)(11)Individual #3 is considered a choking risk and is on a pureed diet. Her physical exams, dated 1/18/2016 and 12/7/2016, state that she has no restrictions with her diet.The physical examination shall include: Special instructions for an individual's diet.The physical exam had a section for dietary restrictions and Health Maintance Needs. It has been revised and expanded to include specific food preparation needs: pureed, chopped, soft, thickened liquids and g-tub. In addition, any feeding protocols will be attached to the annual physical for physician review and signature. 05/15/2017 Implemented
2380.173(1)(ii)Identifying marks are not listed in the records for Individual #1, Individual #2, Individual #3, and Individual #4. (Repeat violation: 4/7/2016)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.New Face sheets have been completed to include `Identifying Marks¿, which was inadvertently forgotten last year with the new face sheets. All faces sheets will be updated no later than 8/1517 05/15/2017 Implemented
2380.181(d)Individual #4's 2016 assessment is not signed and dated by his Program Specialist.The program specialist shall sign and date the assessment.Assessment has been signed and dated. Files will be reviewed by a designated person responsible for quality. 05/01/2017 Implemented
2380.181(e)(5)This area was not assessed in Individual #2's assessment dated 1/16/2017.The assessment must include the following information: The individual¿s ability to self-administer medications.The section referring to the individual's ability to self-medicate has been completed. Files will be reviewed by a designated person responsible for quality. 05/01/2017 Implemented
2380.181(e)(14)Both water safety & the ability to swim were not assessed in Individual #2's assessment dated 1/16/2017. Water safety was not assessed in Individual #3's assessment dated 1/10/2017.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Individual #2 - Water safety information added to their assessment. Individual #3 - The ability to temper water was added to the existing water safety information. Files and assessment will be reviewed by a designated person responsible for quality. 05/01/2017 Implemented
2380.186(a)Individual #2 was admitted to program on 11/22/2016. As of the date of inspection, no ISP Reviews have been done. Individual #3 had 2 ISP Reviews on file, dated 1/10/2017 and 4/22/2015. The time frame between 4/22/2015-1/10/2017 and 1/10/2017-4/27/2017 (dated of inspection) exceeds the 3 month requirement. (Repeat violation: 4/7/2016)The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Individual #2 ISP reviews completed to correspond with the meeting reviews conducted at the three month mark. - completed 5/1/17 Individual #3 - ISP reviews printed and on file as required - completed 5/1/17 Last year a system was developed which identified when ISP quarterlies are due. Over site to insure ISP reviews are completed as expected must be completed by a designated person and can be done through regular file reviews. 09/01/2017 Implemented
2380.186(b)Individual #2, Individual #3, and Individual #4 did not sign completed ISP Reviews as required. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individuals had not been signing ISP reviews. A signature line has been added to the quarterly report form to insure this is completed in the future. The program specialists are responsible to obtain signature at time of review. 05/15/2017 Implemented
SIN-00090987 Renewal 04/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)The criminal history record for direct care worker (staff 1) was requested on 2/4/2016 and indicates that it is under review. Staff 1 was hired on 12/7/2015. A criminal history check that is under review is not completed as it does not indicate that there is or is not a criminal record.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.The CEO has attended trainings on proper PA and FBI criminal checks within the last six months. The new policy states that all clearances will be on sight prior to any employee start date. The CEO is responsible to insure the policy is followed as written 09/30/2016 Implemented
2380.36(b)There was no record of the CEO's training for the training year of 7/1/2014-6/30/2015.The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.CEO had completed 24 hours of training, however there was a lack of clear documentation in one place. A new documentation and tracking system is being developed to better manage staff training hours. 09/01/2016 Implemented
2380.36(c)Direct Care Worker (staff 2's) record indicates that she received 21 hours of training during the training year or 7/1/2014-6/30/2015. Staff 2 did not meet her required annual training hours of 24. Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.DSW #2 had completed 24 hours of training for the 7/1/14-6/30/15 fiscal year, although three online trainings lacked documentation. A new documentation and tracking system is being developed to better manage staff training hours. 09/01/2016 Implemented
2380.91(a) Individual 1 has an admission date of 9/3/2015. However, individual 1 did not receive his fire safety training until 10/9/2015. 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.Individual 1 received fire safety training within first week of program, however the training was not adequately documented. The training on 10/9/15 as the annual fire safety training completed for whole program. A checklist with clear fire safety documentation is being developed for new admissions by 9/1/16 09/01/2016 Implemented
2380.113(a)The director/program specialist (staff 4) had a physical completed on 1/29/2014 and as of the date of the inspection had not completed another physical. The physical is 69 days late. Repeat Violations - (2/11/2015)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 staff members, including temporary, substitute and volunteer staff persons who have direct contact with individuals, serves or prepares food for more than 5 days in a 6 month period shall have a physical examination within 12 months prior to employment and every 2 years afterwards. Compliance will be monitored by the administrative assistant and overseen by the CEO and program Specialist 09/30/2016 Implemented
2380.113(c)(2)Direct Care Worker (staff 3) had a TB test on 1/25/2012 and not again until 8/27/2015 (20 months late). Repeat violation - (2/11/2015) 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.It had been suggested by staff member 4's physician that chest x rays conducted on 1/17/13 would serve as sufficient evidence of 'negative for TB'. In the future only the TB skin testing with negative results or chest x rays for positive results will be accepted. 04/11/2016 Implemented
2380.173(1)(i) Individuals 1 record does not contain his sex or social security number. The sex of individuals 2, 3, and 4 is not listed in their record. Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.Individual's sex, and social security numbers has been included on new face sheets formulated in response to 2380. 173 (I)(i). All individual records are being updated to include this information. 07/30/2016 Implemented
2380.173(1)(ii) The records of individuals 1, 2, 3, and 4 do not include race, height, weight, hair or eye color, or any identifying marks. 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.Individual's race, height, weight, hair and eye color and identifying marks have been included on new face sheets formulated in response to 2380. 173 (I)(ii). All individual records are being updated to include this information. 07/30/2016 Implemented
2380.181(d) Individual 1's initial assessment dated 10/30/2015 is unsigned by the program specialist. Individual 2's assessment dated 9/30/2015 is unsigned by the program specialist. The program specialist shall sign and date the assessment.Assessments for individuals 1 and 2 were signed, dated and sent to licensing on 4/11/16 04/11/2016 Implemented
2380.186(a) Individual 1's record does not contain any ISP reviews. Two ISP reviews were due in 12/2015 and 3/2016. The most recent ISP review for individual 4 was 10/10/2015. Individual 4 should have received an ISP review in 1/2016. Repeat Violation - (4/2/2014). The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.A system has been put into place where what month quarterlies are due for each individual is identified. The Program Specialist is responsible to review the ISP and complete the quarterlies as identified. The quarterlies include a review of monthly documentation of an individual's progress and participation, the documentation of modification, addition or deletion of services based on the individual's current needs and/or abilities. The Program Specialist has been re-trained on the importance of following the system. 09/30/2016 Implemented
SIN-00075044 Renewal 02/11/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Individuals 1,2,3 and 4 plus others are not safe to use or avoid poisons. They have access to the kitchen area where a one gallon container of Automatic Dishwasher Gel was stored unlocked under the kitchen sink, The label on the container read: " Harmful if Swallowed ".Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Areas under the sink was left unlocked. Upon investigation, the students/staff who use the main kitchen evacuated for a fire drill, then immediately left the school for a filed trip, without returning to check that all was secure. Staff was re-trained on the need for all poisons to be locked,(completed on 2/12/15). To avoid this from happening in the future, the staff in the kitchen will initial a schedule, showing that the kitchen was secure when staff left the kitchen. 04/15/2015 Implemented
2380.89(e)There are two program rooms----the Orange room and the Purple room. Documentation showed that the Individuals in the Orange room always went out the front door and Individuals in the Purple room always went out the back door during the past twelve months of fire drills. Two exits were used but Individuals did not alternate exits.Alternate exit routes shall be used during fire drills.A schedule will be established, which insures that regular routes are blocked at least once in a quarter period, to insure individuals will learn to evacuate by more than one exit. Schedule will be established ,implemented and monitored by the CEO and program specialist 04/30/2015 Implemented
2380.111(c)(3)The last recorded Diptheria/Tetanus shot for Individual #1 was 1997 which exceeds the allowable ten year limit.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 had a Diphtheria/Tetanus shot on 3/12/15, in conjunction with immunizations recommended by the US Public Health Service Center for Disease Control, Atlanta, GA. In addition the DPT has been included in the physical letter to the parents, which states individuals will not be allowed to attend program without proof of inoculation. The program specialist monitors compliance and suspend attendance if necessary. 03/19/2015 Implemented
2380.111(c)(5)Individual #3 had a Tuberculin Skin Test on 02/29/2012 and again on 04/11/2014 which exceeds the allowable two year limit.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.Individual #3 had a discrepancy in due date and TB received due to doctor availability due to weather issues and rescheduled appointments. The physical letter was established after this incident and clearly states individuals must have a TB test every two years, and failure to do so will result in the individual not being permitted to attend program. The program specialist monitors compliance and suspend attendance if necessary. 03/19/2015 Implemented
2380.113(a)Staff #1 was hired on 09/02/2014 and did not have a physical examination done until 02/06/2015.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 office manager, program specialist and CEO all took part in hiring expectations/requirements. As a result, there was not consistent oversight as to what was completed. The new protocol contains a checklist of necessary/required paperwork, to be managed by the CEO, for all new employees. The checklist will be forwarded to the program specialist for follow up. 04/01/2015 Implemented
2380.113(c)(2)Staff #1 ws hired on 09/02/2014 and did not get the Tuberculin Skin Test until 02/09/2015.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 physical and TB skin test requirement are now included in the checklist and new hire packet. The new hire packet is reveiwed by the CEO and Program Specialist to ensure compliance. 04/01/2015 Implemented
2380.181(a)Individual #2 was admitted to the Program on 06/23/2014 and as of 02/11/2015 did not have an Assessment.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 #2's assessment has been completed and filed by the program specialist. The Program Specialist will ensure that all assessments are completed annually. 03/19/2015 Implemented
2380.186(c)(1)Individuals #1 was admitted to the Program on 06/16/2014 and Individual #2 was admitted on 06/23/2014 and neither Individual had any quarterly reviews of their ISP's.The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Monthly reviews and quarterlies will be completed. A tracking system which outlines when quarterlies are due will be implemented by the program specialist 04/15/2015 Implemented
SIN-00062699 Initial review 04/02/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(a)On April 2, 2014 there was no documentation that an ISP review was completed for Individual #1 for the months of July, 2013, and April 2013.(a)  The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP.The Program Specialist will develop a tracking system which identifies all quarterly reviews due by calendar month to insure all reports are completed every three months by the date outlined in each participant's ISP, as per chapter regulations. The program Specialist will insure that the records are reviewed on a quarterly basis to insure quarterlies have been completed and required paperwork is in place. 06/30/2014 Implemented
SIN-00067407 Renewal 08/20/2014 Compliant - Finalized
SIN-00067293 Renewal 08/18/2014 Compliant - Finalized
SIN-00065954 Renewal 07/22/2014 Compliant - Finalized