Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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.1007 | Autism 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 |