Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00239863 Renewal 12/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)2380.20(a) Criminal History background checks for staff number 1, a new hire, was completed late. The date of hire was 7/3/2023, and the background check was requested on 7/10/23.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.Background check was completed on their calendar 5th day of work but not the 5th consecutive day from hiring. Hiring staff has been education on manner and have made correction to their process. As part of the update to the onboarding process, all new hires are required to complete their background check prior to starting with ACF.COO and CEO were informed/reeducated on the regulation involving the background checks for new hires as of 12/5/2023. 12/05/2024 Implemented
2380.67(a)67a One of the closet doors is broken in the upstairs activity area.Furniture and equipment shall be nonhazardous, clean and sturdy.Closet door in upstairs activity room has been replaced as of 12/6/2023. A monthly checklist has been created that the Program Specialist/Program Coordinator will utilize to ensure that the facility and all the equipment is sturdy along with being free of holes for the Autism Cares Foundation (ACF). 12/06/2023 Implemented
2380.111(a)111a Most recent physical exam for individual number one is dated 11/8/22 which is greater than 1 year ago.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.ACF CPS Program Staff was able to obtain an updated proof of annual physical of participants on 12/05/2023 and provide a copy to the auditing team for review. 12/05/2023 Implemented
2380.111(a)111a Individual number two physical exam is dated 8/4/22 which is greater than 1 year ago.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.ACF CPS Program Staff was able to obtain an updated proof of annual physical of participants on 12/05/2023 and provide a copy to the auditing team for review. 12/05/2023 Implemented
2380.181(e)(14)181e14 Individual number one's annual assessment dated 1/9/23 does not note the ability to swim in annual assessment.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Program Specialist has reviewed the regulation and added this information to their reporting structure going forward. 12/05/2023 Implemented
SIN-00215777 Renewal 12/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #3 Criminal Record Check was not submitted timely, staff was hired on 03/30/2022 and check was not requested until 04/14/2022.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.Immediate Action: Beginning on 6/6/2022, new hires are required to show their PA criminal background check before their date of hire. New Hire Checklist has been updated to require the background check. Currently, the CEO is responsible for all HR duties; if this responsibility shifts, the New Hire Checklist will transfer. 06/06/2022 Implemented
2380.53(a)There was disinfected cleaner (liquid) on the counters in 2 bathrooms and the recreation room activity closet, which are located on the 2nd floor.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Immediate Action: All disinfectants and cleaners have been removed from the bathrooms on 12/5/2022. 12/05/2022 Implemented
2380.62The emergency numbers list was not posted on or by every phone in office number one.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.Emergency numbers were posted near each of the 8 land lines in the facility. 12/13/2022 Implemented
2380.70(b)No blanket or pillow was in the first aid room area.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.Immediate Action: On 1/16/2023, the Program Supervisor supplied a pillow and blanket for the first aid room. The staff will be instructed to leave the pillow and blanket on the cot in the first aid room. 01/19/2023 Implemented
2380.70(d)No scissors were located in the first aid kit.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 inspection, there were several first aid kits in the facility, none with scissors. One large first aid kit has been attached to the wall in the First Aid Room, making it clear where the supplies are stored. The staff were instructed to leave the scissors in the first aid kit and notify the Program Coordinator if supplies need to be replaced. 12/15/2022 Implemented
2380.89(g)There was no designated area (meeting place) for the evacuation all 3 drills (August, September, and October 2022). Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Immediate Action: The fire drill attendance form was changed in November 2022 to add the designated meeting place. 11/30/2022 Implemented
2380.111(a)There was no Physical exam on file. Individual #2 did not have a physical exam within 12 months prior to admission and annually thereafter.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Immediate Action: Individual #2 was suspended on 12/9/2023 from attending the program until her team provided a current physical/TB. 12/05/2022 Implemented
2380.111(c)(3)For Ind. #1 The TDAP vaccine was last completed on 10/3/2002. There was not record on file showing that this vaccine was completed.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 and the team are not plannng to complete another TDAP vaccine. The Program Specialist will complete the records to show N/A. 12/19/2022 Implemented
2380.113(a)Staff person #2 did not have a physical examination every two years as required last physical was completed on 08/28/2018 and current examination is dated 10/14/2020A 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.Immediate Action: Beginning on 6/6/2022, new hires are required to get a physical examination on their first 1-2 days of hire. New hires are sent to a local urgent care to recieve the physical and TB test; the doctor sends the physical results to Autism Cares Foundation. 06/06/2022 Implemented
2380.113(c)(2)Staff person #2 did not have a TB test timely (every 2 yrs) last test was given 08/28/2018 and current test was not given until 10/14/2020.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.Immediate Action: Beginning on 6/6/2022, new hires are required to get a physical examination and TB on their first 1-2 days of hire. New hires are sent to a local urgent care to recieve the physical and TB test; the doctor sends the physical results to Autism Cares Foundation. The CEO is currently providing HR duties; She has checked all current staff files to ensure a current physical/TB. 06/06/2022 Implemented
2380.173(1)(ii)The content record- face sheet did not include Ind. #1 identifying marks. The content record- face sheet did not include religious affiliations.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.Immediate Action: Any identifying marks have been added to individual #1 file. 12/07/2022 Implemented
2380.17(i)The agency failed to finalize the incident report through the department and notify the Department in writing to request an extension for incident numbers 8938353, 8938340, 8938340, 8938327, 8938327, 8938311, 8938311, 8937862.The facility shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the facility notifies the Department in writing that an extension is necessary and the reason for the extension.Immediate Action: New CEO has been trained by a county representative in November 2022 and Jan 2023 on the incident management system portal. 01/25/2023 Implemented
2380.36(a)All employees of Autism Cares were not trained annually in Fire Safety, current training was completed 04/21/2022 and previous training was done 10/01/2019.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.Due to Covid closures and openings of the facility throughout 2020-2022, previous leadership did not provide annual fire safety training to staff. 12/05/2022 Implemented
2380.36(b)Staff #1 was not trained annually by a fire safety expert in the specific training areas, hiring date was 06/28/2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Immediate Action: Program Specialist will not provide any fire safety training to individuals until receiving fire safety training. 12/05/2022 Implemented
2380.129(a)Staff personal #4 did not successfully complete a department-approved medication administration course prior to administrating medication. Based on Staff #4 Training Certificate staff personal can continue training.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).Immediate Action: During the inspection on 12/5/2023, Staff #4 was pulled from administering medications to individuals in the program. 12/05/2022 Implemented
2380.181(f)Ind. #2 record did not show that the assessment was sent to the individual's plan team.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The new Program Specialist will ensure that assessments are sent to the individual's team in a timely manner. 12/05/2022 Implemented
SIN-00163955 Renewal 10/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(d)It could not be determined if staff #2 had training in the areas of services for people with disabilities and program planning and implementation within 30 days of initial employment, there was no documentation found in the record.Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.Training was completed by staff #2 on 9/14/18 which is within one year prior to employment. The CEO will ensure staff complete the training during the orientation period of employment. The date will be placed on the employee checklist. 10/14/2019 Implemented
2380.36(f)The fire-safety training for staff members #1, and #2 was conducted on the same dates 7/23/18, then 10/1/19. This training was not completed within the annual regulated timeframe.Program specialists and direct service workers shall be trained annually by a fire-safety expert in the training areas specified in subsection (f).The CEO will ensure the fire-safety training will be completed on or before October 1 of each year. The CEO will contact the contractor 30 days prior to the due date of the annual training. 10/14/2019 Implemented
2380.58(a)There was a chair on the first floor that was torn on both arms with padding that was coming out.Floors, walls, ceilings and other surfaces shall be in good repair.The chair was removed and disposed of on October 8, 2019. During the monthly site inspection, the Program Coordinator will complete a safety inspection which includes checking to ensure screens, windows, and doors are in good working order. CEO will check the form before filing to ensure all screens, windows and doors are in good working order. CEO will place an email repair request for those items needing repair. 10/08/2019 Implemented
2380.63(b)There was a set of closet doors on the second floor activity area that were not connected at the bottom which could lead to them falling off of the track.Screens, windows and doors shall be in good repair.The closet was repaired on 10/18/19. As safety is imperative there will be monthly safety checks to ensure compliance. The safety checks will be completed on a form and maintenance or repairs will be documented on those forms to avoid not being aware of any maintenance issues. The forms will be completed by Program Coordinator to ensure cooperation and accuracy. CEO will check the form before filing to ensure all screens, windows and doors are in good working order. CEO will place an email repair request for those items needing repair. 10/18/2019 Implemented
2380.89(a)An unannounced fire drill record was not kept for the months of (November 2018, December 2018, January 2019, and February 2019).An unannounced fire drill shall be held at least once a month.January 2019 and February 2019 forms was located, after a building search unable to locate the other missing forms. The CEO will ensure an unannounced fire drill is conducted every month. The CEO will ensure the forms are filed in the designated location and a digital copy is obtained. 10/25/2019 Implemented
2380.89(c)On the agency's Fire Drill Attendance List, the Fire Alarm Operative question was left blank for July 2019 and August 2019.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.On 10/10/19, the Program Coordinators were instructed to place n/a or none on the form if it was not applicable. The CEO will check the form before being filed. 10/10/2019 Implemented
2380.89(d)The amount of time for evacuation exceeded the 2 ½ minutes: July 12, 2019 the evacuation time was listed at 3 minutes and 30 seconds (Problems encountered was left blank). No additional drill was conducted during the month. The amount of time for evacuation for 6/27/2019 was 5 minutes 47 seconds, There were no additional drill conducted during the month. no documentation of an extended evacuation time found at inspection.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire-safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire-safety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.The Southampton fire marshal was contacted on 10/11/19. The fire marshal determined that due to the physical limitations of the current clients, the distance of the current evacuation location would not be within the 2.5 minutes. The evacuation location was changed to the back of the loading area of the business across the parking lot for ACF. The fire drill conducted on 11/25/19 was 1.9 seconds. The fire drill form was revised on 10/23/19 to reflect another drill is needed if the time is greater than 2.5 minutes. The CEO will ensure the monthly fire drills are completed within the 2.5 time frame. If the drill is not competed within the acceptable time frame another drill will be completed for the month. 10/11/2019 Implemented
2380.91(a)Individual#2 Fire Safety training was re-instructed late. Last fire safety training was completed March 14, 2018 and current training completed August 14/2019.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire-safety, 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.CEO has agreed to schedule yearly fire safety training in October of every year to coincide with clocks turning back. As the agency realizes how important it is to attain fire safety and practice with our clients scheduling it the same time of year ensures it becomes routine and expected to happen at this time. Until October when it will be scheduled the company will have an additional training this year to get agency on track with completing yearly. All forms and attendance will be reviewed with a deadline of December for anyone missing training. 11/26/2019 Implemented
2380.111(a)The Annual Physical Examination for individual#3 was last completed 09/12/2017 and not completed again until 10/17/2018. The annual exam is late.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialist will contact the families 30 days prior to the expiration of the current physical. If no physical is obtained by the due date. The individual will be unable to attend the program until the physical is complete. 10/14/2019 Implemented
2380.111(c)(1)Individual#1's physical dated 10/23/18 did not indicate if medical history was reviewed. The copy of the form had that line chopped off.The physical examination shall include: A review of previous medical history.Unable to obtain a corrected physical. The Program Specialist will ensure all clients physical are completely filled out with no blanks. If blanks occur the Program Specialist will contact the family with the concerns and provide a 30 day window for corrections to the form. 10/14/2019 Implemented
2380.111(c)(4)Individual#1's physical dated 10/23/18 did not indicate either a vision or hearing screen. The question was left blank. On Annual Physical Examination Form for individual#3 dated 10/17/2018 the Vision and Hearing screening was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Unable to obtain a corrected physical. The Program Specialist will ensure all clients physical are completely filled out with no blanks. If blanks occur the Program Specialist will contact the family with the concerns and provide a 30 day window for corrections to the form. All physicals will be entered into the client file after program specialist has reviewed the form for any blanks or necessary actions that need to occur. The program specialist and CEO will be reviewed prior to placement into file. If there are any blanks the form will be returned to parents to have physician complete without blanks within 30 days or client will be unable to attend program until complete. 10/14/2019 Implemented
2380.111(c)(5)The Annual Physical Examination for Individual #3 dated 10/17/2018 and the exam dated 09/12/17 the Tuberculin skin testing was not completed and left blank.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.Unable to obtain a corrected physical. Individual #3 has been discharged from the program on 11/15/19. The Program Specialist will ensure all clients physical are completely filled out with no blanks. If blanks occur the Program Specialist will contact the family with the concerns and provide a 30 day window for corrections to the form. 10/14/2019 Implemented
2380.111(c)(10)Individual #1's physical dated 10/23/18 did not indicate information pertinent to diagnosis in case of an emergency. It was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Unable to obtain a corrected physical. The Program Specialist will ensure all clients physical are completely filled out with no blanks. If blanks occur the Program Specialist will contact the family with the concerns and provide a 30 day window for corrections to the form. 10/14/2019 Implemented
2380.113(a)Staff #1,and staff #2 did not have a completed physical exam in either record.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 and #2 are required to obtain the physicals by December 31, 2019 that are incompliance with ODP standards. A new form was created on 11/25/19 to comply with ODP standards. The Executive Director will ensure upon hire that all staff complete a physical which is in compliance with ODP standards. 12/31/2019 Implemented
2380.173(1)(ii)Individual #2's record did not include Identifying Marks. Individual #3's client record did not include, Race, Hair Color or 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.A new face sheet was created. Individual #2 face sheet was updated on 11/26/19. Individual #3 was discharged from the program on 11/15/19, the face sheet was unable to be update. The face sheet will be updated annually by the Program Specialist to ensure the forms are accurate. 11/26/2019 Implemented
2380.181(a)The Annual updated Assessment for individual #2 was not completed for 2018. Individual #3 did not have an initial assessment completed 60 calendar days after the admission date of 1/28/19.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.Unable to complete an assessment for 2018 for individual #2 due to staff no longer employed at ACF. The initial assessment was completed for individual #3 by the CEO on 10/17/19. The Program Specialist will complete the assessments 30 days prior to the annual review date or 60 calendar for a new admission. The CEO will review the plan before being submitted to the SC. 10/17/2019 Implemented
2380.181(c)The assessment for individual #2 dated 01/13/2019 did not state what the assessment was based on such as (interview, progress notes and observations).The assessment shall be based on assessment instruments, interviews, progress notes and observations.An addendum was written by the CEO, the original document writer for individual #2 on 10/19/19. The Program Specialist will use the current ODP recommended form. Once the assessment is completed, it will be given to the CEO for a review before being submitted. 10/19/2019 Implemented
2380.181(e)(7)The assessment dated 01/13/2019 did not state if individual#2 had knowledge of the danger of heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.An addendum was written by the CEO, the original document writer for individual #2 on 10/19/19. The Program Specialist will use the current ODP recommended form. Once the assessment is completed, it will be given to the CEO for a review before being submitted. 10/19/2019 Implemented
2380.181(e)(8)The assessment dated 01/13/2019 did not state if individual#2 had the ability to evacuate in the event of a fire.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.An addendum was written by the CEO, the original document writer for individual #2 on 10/19/19. The Program Specialist will use the current ODP recommended form. Once the assessment is completed, it will be given to the CEO for a review before being submitted. 10/19/2019 Implemented
2380.181(e)(13)(v)The area of recreation did not include any statements as to the progress that individual#1 has made during the previous year at the program.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation.An addendum was written by the Program Specialist 10/16/19. The Program Specialist will use the current ODP recommended form. Once the assessment is completed, it will be given to the CEO for a review before being submitted. 10/16/2019 Implemented
2380.181(e)(14)The assessment dated 01/13/2019 did not indicate if individual #2 had knowledge of water safety or the ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.An addendum was written by the CEO, the original document writer for individual #2 on 10/19/19. The Program Specialist will use the current ODP recommended form. Once the assessment is completed, it will be given to the CEO for a review before being submitted. 10/19/2019 Implemented
2380.39(a)(1)Staff #3 completed 23.5 hours of annual training related to job skills and knowledge.The following shall complete 24 hours of training related to job skills and knowledge each year: Directive service workers.Addition information was obtained after the date of the audit. Documentation of additional annual training hours were found. The total annual training hours for staff #3 is 28. Staff will be assigned 24 hours of annual training. The hours will be monitored for compliance during monthly supervision with staff by the Program Specialist. 10/15/2019 Implemented
2380.155(a)Individual#1's day program is currently implementing the use of a helmet during behaviors when individual#1 is hitting himself in the head as the result of a triggered event. The behavioral plan implemented on 6/4/19 speaks to the use of this helmet briefly but there is no indication where the helmet came from and if there was a prescribing professional who made the recommendation for the use of this device. Licensing staff spoke to both the agency director and the behavioral specialist, who stated that they have been unsure about the adaptive equipment and where it began being used. A look at the past two behavioral support plans under two separate agencies do not seem to mention the helmet at all. Therefore, it is suggested that more information is collected before the use of this helmet is implemented in the future. These things include a prescription for the device, training on how to implement and follow up on how to keep and care for the device over time. Also, during conversation with agency staff it was learned that it may have possibly been implemented by individual#1's mother.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 2380.154 (relating to human rights team), prior to use of a restrictive procedure.The helmet use was discontinued on 10/8/19, the family was notified on 10/9/19. Staff were instructed on 10/8/19 to discontinue the use of the helmet as well as what techniques to use with individual #1 to prevent head injuries. A formal training was held on 10/23/19. A meeting was held with the SC, Program Specialist, CEO, Case manager, and behavior specialist. The behavior specialist¿s supervisor attended via phone. The helmet and the revision of the needed changes to the plan were discussed. The family on 11/22/19 obtained a prescription for utilization of the helmet. The helmets care was on the website link the family sent to the Program Specialist. The Behavior Specialist provided the revised plan to ACF on 12/5/19. The Human Rights Committee will meet on 12/13/19 to review plan. The Behavior Specialist will train the staff within one week of a positive decision of the committee. Moving forward, ACF will only accept plans with a helmet as a restrictive procedure. Prior to use, the Program Specialist will obtain the prescription, care of the helmet, approval from the Human Rights Committee and staff will be trained before implementation of a helmet. The prescription will be on site in the file before any action is taken. The first level of assistance with client will be not to use helmet but if client is unresponsive to plan, the helmet will be used to prevent injury to client. 10/08/2019 Implemented
2380.156(a)Staff members #1, #2 and #3 did not have record or documentation of being trained in the use of specific techniques or procedures that are used as it relates to individual #1.A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used.While waiting for the updated behavior support plan for individual #1, the Program Specialist conducted informal training on 10/8/19 with the staff and formal training on 10/23/19 regarding individual #1. The updated plan was received on 12/5/19. The Human Rights Committee will meet on 12/13/19. If approved, training with the staff will be conducted by the behavior specialist. The Program Specialist will complete training for new hires during the orientation process regarding specific techniques and/or procedure for all clients. In the future, before someone begins a behavioral plan, all staff will be educated about the problem issue that the plan is addressing and the details in the plan. At that time all staff will be trained how to implement the plan. One week later all staff will meet to discuss what is working with the plan and if something is not working so the plan can be readjusted and staff educated about any changes to be implemented. In two weeks¿ time staff will meet again to discuss plan to be sure it is still relevant and working accordingly. 12/18/2019 Implemented
Article X.1007Autism Cares Foundation is required to meet all requirements of X of the Public Welfare Code and of the applicable statues, ordinances, and regulations (62 P.S. 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA)(35 P.S. 10225.101--10225.5102) and its regulations (6 Pa. Code Ch. 15) During inspection multiple staff member's records did not document if the staff had lived in Pennsylvania for the past 2 years prior to employment .When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.FBI checks have been required of the 7 staff records reviewed. PA Criminal history checks have been completed for 1 staff out of compliance. The other two staff are within the year parameter. All other staff hired within the last year records were reviewed. Any staff out of this compliance were require to provide the appropriate clearance. Prior to the first day of employment, the Executive Director will ensure that all background checks are completed. ACF has added a form to the application indicating a person¿s residency. ACF will also require potential employees to provide an FBI check prior to employment. 12/06/2019 Implemented
SIN-00139374 Renewal 08/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #1's criminal history check was done on 7/24/18 which was after hired date of 11/6/17.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.An employment check list has been created. Personnel files have been reviewed and notices have been given to employees to obtain the check within 30 days. All criminal history checks for staff are required and will be obtained prior to start date. The criminal history check accepted by the employer will be within 6 months of employment. The CEO will review the employment files before being given to the Executive Director for storage. This POC will be effective immediately. A random sample of personnel files will be reviewed semiannually beginning June 2019. 06/01/2019 Implemented
2380.111(a)Individual #2's physical exam was completed on 10/26/17 which is after the admission date of 8/14/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. A tracking document has been created which include the date of the last physical. This document will be managed by the Program Specialist. In the absence of the Program Specialist, the CEO will maintain the document. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.111(a)Individual #3's current physical is dated 7/8/16.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialist responsible to correct this has resigned and no longer employed at ACF A tracking document has been created which include the date of the last physical. This document will be managed by the Program Specialist. In the absence of the Program Specialist, the CEO will maintain the document. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.111(c)(3)there was no record of immunization for Individual #1.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. A tracking document has been created which includes the immunization record. This document will be managed by the Program Specialist. In the absence of the Program Specialist, the CEO will maintain the document. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.111(c)(5)Individual #1's most current TB test was done on 9/2/15.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 Program Specialist responsible to correct this has resigned and no longer employed at ACF. A tracking document has been created which includes the date of the TB test for clients. This document will be managed by the Program Specialist. In the absence of the Program Specialist, the CEO will maintain the document. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.113(a)Staff #1 and #2's records did not include documentation of physical exams.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 physical exams for staff are required and will be obtained prior to start date. The physical accepted by the employer will be no longer than within 6 months of employment. An employment check list has been created. The CEO will review the employment file before being given to the Executive Director for storage. Personnel files have been reviewed and notices have been given to employees without physicals to obtain one within 30 days. Physicals will be updated every two years. This POC will be effective immediately. A random sample of personnel files will be review semiannually beginning June 2019. 06/01/2019 Implemented
2380.113(c)(2)Staff #1 and #2's records did not include documentation of TB screening.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.An employment check list has been created. . Personnel files have been reviewed and notices have been given to employees without TB results to obtain one within 30 days. All TB results for staff are required and will be obtained prior to start date. The TB results accepted by the employer will be within 6 months of employment. The CEO will review the employment file before being given to the Executive Director for storage. TB tests will be updated every two years. This POC will be effective immediately. Random sample of personnel files will be reviewed semiannually beginning June 2019. 06/01/2019 Implemented
2380.181(a)Individual #2's initial assessment was done on 11/14/17 which is beyond the 60 days after admission on 8/14/17Each 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.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The major repository of the initial start dates of all consumers will be entered with initial assessment and updated assessments dates into a tracking document. This document will be managed by the Program Specialist. In the absence of the Program Specialist, the CEO will maintain this document. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review to CEO. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.181(c)Individual #3's assessment dated 4/18/18 was not signed by the program specialist.The assessment shall be based on assessment instruments, interviews, progress notes and observations.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The new Program Specialist will be trained on the procedure and requirements of the regulations to complete the assessment. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.181(d)Individual #3's assessment dated 4/18/18 was not signed by the program specialist.The program specialist shall sign and date the assessment.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The new Program Specialist will be trained on the procedure and requirements of the regulations to complete the assessment. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner 03/01/2019 Implemented
2380.181(d)Individual #1's assessment dated 12/1/17 was not signed by the program specialist.The program specialist shall sign and date the assessment.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The new Program Specialist will be trained on the procedure and requirements of the regulations to complete the assessment. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner 03/01/2019 Implemented
2380.181(e)(7)Individual #2's assessment dated 11/14/17 did not assess the Individual's knowledge of heat source.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The new Program Specialist will be trained on the procedure and requirements of the regulations to complete the assessment The agency has learned it is necessary to review and evaluate all assessments to be in a better position to catch and correct anything missed by the Program Specialist. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.181(e)(8)Individual #2's assessment dated 11/14/17 did not assess the Individual's ability to evacuate in the event of a fire.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The new Program Specialist will be trained on the procedure and requirements of the regulations to complete the assessment. The agency has learned it is necessary to review and evaluate all assessments to be in a better position to catch and correct any thing missed by the Program Specialist. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.181(e)(12)Individual #2's assessment dated 11/14/17 did not include recommendation for specific areas of training.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The new Program Specialist will be trained on the procedure and requirements of the regulations to complete the assessment. The agency has learned it is necessary to review and evaluate all assessments to be in a better position to catch and correct any thing missed by the Program Specialist. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
2380.181(f)Individual #2's assessment dated 11/14/17 was not sent to the Support Coordinator at least 30 calendar days prior to 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).The Program Specialist responsible to correct this has resigned and no longer employed at ACF. The new Program Specialist will be trained on the procedure and requirements of the regulations to complete the assessment. The CEO will hold the Program Specialist accountable to submit the assessment 7 days prior to the due date for review. Again, in reviewing the process for all assessments we feel with the new process it will allow a much more thorough and expedient response to ensuring the assessments are complete and seen by the appropriate parties. This POC will be in effect immediately. There will be a quarterly chart review beginning March 2019 to ensure this is completed in a timely manner. 03/01/2019 Implemented
SIN-00119389 Renewal 06/29/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(d)The first aid kits located on the first and second floor did not contain scissors.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.All first aid kits in the building now contain scissors. First aid kits will be checked on a monthly basis to ensure all required items are present. 06/30/2017 Implemented
2380.91(a)Individual 1's date of admission was 7/25/16 and fire safety training was completed on 08/24/16. Individual # 2's date of admission was 05/30/17 and there was no documenation of fire safety training.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.All individuals admitted after June 30th have received fire safety training on the date of admission. The Autism Cares Foundations have updated intake procedures to ensure this will occur, as well as documentation of fire safety training. Individual #2 received Fire Safety training on June 2, 2017. Please refer to document sent to inspector. 06/30/2017 Implemented
2380.111(a)Individual # 1's most recent physical examination was dated 05/31/2016.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #1 had a physical dated 3/7/17. Please see documentation sent to the inspector. Moving forward the Autism Cares Foundation will audit all intake packets to ensure updated physicals, and on a monthly basis to make sure physicals are completed annually. 08/25/2017 Implemented
2380.111(c)(3)Individual #1's record did not document an updated DT vaccination.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 received an updated DT vaccination on 8/21/2017. Please see documentation sent to the inspector. Moving forward the Autism Cares Foundation will audit all intake packets to ensure updated vaccinations, and on a monthly basis to make sure all vaccinations are completed. 08/21/2017 Implemented
2380.111(c)(5)Individual #2's record did not document current TB testing.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 #2 received an updated TB test on 8/23/2017. Please see documentation sent to the inspector. Moving forward the Autism Cares Foundation will audit all intake packets to ensure updated TB tests, and on a monthly basis to make sure all TB tests are completed every two years. 08/23/2017 Implemented
2380.171(a)Individual # 1 's record did not document emergency information.Emergency information for individuals shall be easily accessible at the facility.Individual #1 has a form in their file documenting emergency information, and all individuals in the program have these forms filled out on intake. Please refer to document sent to inspector. 06/30/2017 Implemented
2380.173(1)(ii)Individual # 1 and 2's record did not document hair color, eye color, and race. Individual #2's record also did not document 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.The Autism Cares Foundation has revised its intake forms to be filled out by the individual and/or the caregiver to include hair color, eye color, race and identifying marks. Please refer to sample sent to the inspector. For all individuals in the program, we have revised this form to make sure it is included in their files. 08/25/2017 Implemented
2380.173(1)(iv)Individual # 1 and # 2' s record did not document religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The Autism Cares Foundation has revised its intake forms to be filled out by the individual and/or the caregiver to include religious affiliation. For all individuals in the program, we have revised this form to make sure it is included in their files. Please refer to the sample sent to the inspector. 08/25/2017 Implemented
2380.181(c)Individual # 1's assessment dated 9/15/16 did not document the basis of the assessment.The assessment shall be based on assessment instruments, interviews, progress notes and observations.The Program specialist has revised the template format to include the source and basis of the assessment. Please refer to the assessment sent to the inspector. 08/25/2017 Implemented
2380.181(e)(5)Individual # 1's assessment dated 9/15/16 did not document the ability to self administer medication.The assessment must include the following information: The individual¿s ability to self-administer medications.The Program specialist has revised the template format to include the individual's ability to self administer medication. Please refer to the assessment sent to the inspector. 08/25/2017 Implemented
2380.181(e)(6)Individual # 1's assessment dated 9/15/16 did not document the ability to safely use or avoid poisonous materials.The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The Program specialist has revised the template format to include the individual's ability to safely use or avoid poisonous materials. Please refer to the assessment sent to the inspector. 08/25/2017 Implemented
2380.181(e)(8)Individual # 1's assessment dated 9/15/16 did not document the ability to evacuate in the event of a fire.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.The Program specialist has revised the template format to include the individual's ability to evacuate in the event of a fire. Please refer to the assessment sent to the inspector. 08/25/2017 Implemented
2380.183(4)Individual # 1 has 1:1 supervision and there is no documentation of a plan to reduce this level of intensive staffing.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.The Autism Cares Foundation has contacted the team to hold a team meeting to discuss a fade plan for 1:1 support, and to document this in the ISP. The plan suggested will be as follows "Due to _______ significant medical needs (seizures occurring multiple times per hour), _________ required 1:1 support. When seizures reduce from a baseline of multiple times per hour to 3 seizures per week, the team will meet to discuss moving from a 1:1 supervision ratio to a 1:2 supervision ratio." 08/25/2017 Implemented
2380.183(5)Individual # 1 is prescribed psychiatric medication and there was no documentation of a SEEP plan.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The Program Specialist has written a Social Emotional Envioronmental Plan to address Individual #1's needs . Please refer to documentation sent to the inspector. 08/25/2017 Implemented
2380.186(a)Individual # 1's three month ISP review documentation did not document the period reviewed..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 Autism Cares Foundation changed the 3 month review documentation to include a field for period reviewed. Moving forward, all 3 month reviews will include this information. 08/25/2017 Implemented
2380.186(b)Individual # 1's three month ISP review documentation was not signed and dated by the program specalist.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The program specialist has audited all clinical documentation to ensure signatures and dates are on the three month reviews. Moving forward, the program specialist will sign and date all documentation. 08/25/2017 Implemented
2380.186(c)(1)Individual # 1's record did not document monthly reviews.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.The Autism Cares Foundation has created a monthly review template. All clients will have this documentation in their file. Please refer to the sample sent to the inspector. 08/25/2017 Implemented
SIN-00089718 Initial review 02/26/2016 Compliant - Finalized