Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00167760 Unannounced Monitoring 12/16/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)No criminal history background check found in record at inspection for staff member #1.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.Human Resources/ Program Director will ensure that all new hires are being vetted for hire by all required and applicable standards. Also, per the new hire checklist, should ensure that all new hires have all the necessary background clearances to be duly hired and also prior to direct contact/services to individuals. 12/27/2019 Implemented
2380.36(e)Staff member #1's initial fire safety training was not completed prior to working with the individuals. There was no documentation found in the record that staff member#2 was instructed or trained in general fire safety.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 of the local fire department as soon as possible after a fire is discovered.Quality Management and Compliance Team along with Program Director will schedule, track and ensure that each staff member is receiving the required training both upon hire and annually. Each training should have a certificate or proof of training. Routine audits and the implementation of a new hire checklist by the Quality Management and Compliance team for new hires will help ensure compliance, going forward. 01/31/2020 Implemented
2380.36(f)It could not be determined at inspection if annual fire safety training for staff member#1 was completed by a fire safety expert, no documentation found during inspection.Program specialists and direct service workers shall be trained annually by a fire-safety expert in the training areas specified in subsection (f).Quality Management and Compliance Team along with Program Director will schedule, track and ensure that each staff member is receiving the required training both upon hire and annually. Each training should have a certificate or proof of training. Routine audits by the Quality Management and Compliance team for both new hires and seasoned staff files will help ensure compliance. 01/31/2020 Not Implemented
2380.36(h)Documented records of orientation and training could not be found in record at inspection for staff member#2.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Quality Management and Compliance Team along with Program Director will schedule, track and ensure that each staff member is receiving the required training both upon hire and annually. Each training should have a certificate or proof of training. Routine audits by the Quality Management and Compliance team for both new hires and seasoned staff files will help ensure compliance. 01/31/2020 Implemented
2380.53(a)The first aid kit contained Tylenol but was not locked in a secure area.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Management will survey the physical site and assess that each first-aid kit has the required contents. If not, then the specific item(s) will be purchased to help ensure the health and safety of individuals served. Also, each kit will be secured or kept locked when not in use. Management staff will perform walkthroughs daily to ensure compliance and also train staff on what to do if such items are not secured for some reason. 12/27/2019 Implemented
2380.67(a)There were 7 chairs worn with stains throughout the office, (4 green) and one brown chair had a tear in the music room and needed repair. The chair in the program activity area's arm was not fully cushioned and also had stains on the arms. The 2 metal chairs were not sturdy in the program area.Furniture and equipment shall be nonhazardous, clean and sturdy.Both the Management/Maintenance teams will assess all furniture at the physical site to ensure that each are in good/safe condition. Any items that are worn down and or in disrepair will be discarded from the physical site. Ongoing assessments both immediate and weekly by staff will be conducted to ensure the health and safety of individuals-served. 12/27/2019 Implemented
2380.70(b)The first aid area did not contain a first aid kit.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.Management will survey the physical site and assess that each first-aid kit has the required contents. If not, then the specific item(s) will be purchased to help ensure the health and safety of individuals served. Also, weekly assessment of each kit/basic supplies will be conducted to ensure that there is a suitable and required amount at the physical site at all times. 12/27/2019 Implemented
2380.70(d)The first aid kit provided upon physical site inspection was missing tweezers. The second first aid kit provided was also not complete, did not contain assorted bandages.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.Management will survey the physical site and assess that each first-aid kit has the required contents. If not, then the specific item(s) will be purchased to help ensure the health and safety of individuals served. Also, weekly assessment of each kit/basic supplies will be conducted to ensure that there is a suitable and required amount at the physical site at all times. 12/27/2019 Implemented
2380.86Two space heaters were found in the office area underneath 2 staff member's desks.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices.Management/Maintenance team(s) will survey the building to ensure that there are no portable space heaters no permanently mounted and or installed and if any are found, discard them as to protect the health and safety of individuals-served. 12/27/2019 Implemented
2380.91(a)No annual Fire Safety Training found in records for Individuals #1 and #2. There was no initial fire safety training upon admission on 1/2/19 completed for Individual#3. The annual fire safety training on 5/29/19 was the only fire safety training in the record.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.Management along with both the Intake and or Program Specialist will implement an individual training schedule comprised of the necessary training each individual will need as a program participant. Also, the checklist will identify both new admission training and annual training for individuals served. Routine chart audits of no less than monthly for current participants and no later the last service day of the first week of admission will identify noncompliance. 01/31/2020 Implemented
2380.111(a)Individual#1 did not have a current physical exam, Last documented physical exam was completed on 10/3/2018. Annual Physical Examination for Individual#2 was completed late, last physical exam was completed 6/1/18. Current physical was completed 9/26/19. The physical examination for individual#3 was not completed annually. The last completed physical examination was completed on 4/3/18.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program and or Intake Specialist will be retrained on identifying timelines as it relates to the medical information of individuals. Management will also review with the specialists how best to gauge when recurring exams are due by keeping an optimal tracking schedule. This review/retraining will take place no later than 1/31/20. 01/31/2020 Implemented
2380.111(c)(5)The Tuberculin test was not read with negative results every two years for individual#3. The last documented negative reading was dated 4/3/17The 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.Program and or Intake Specialist will be retrained on identifying timelines as it relates to the medical information of individuals. Management will also review with the specialists how best to gauge when recurring exams are due by keeping an optimal tracking schedule. This review/retraining will take place no later than 1/31/20. 01/31/2020 Implemented
2380.111(c)(10)On the physical exam dated 9/26/19 the information pertinent to diagnoses in case of emergency was left blank for individual#2.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Intake and or Program Specialist will review along with management the required information per the physical exam of each individual. If such information is missing, the specialist or designee will contact the caregiver and or individual's physician to obtain such information. Routine chart audits will also help ensure compliance as missing information may be identified. 01/31/2020 Implemented
2380.173(1)(ii)Individual#3's record did not notate identifying marks in the record. The identifying marks field was left blank.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.Intake and or Program Specialist will review along with management the importance of capturing the mandated demographic information of new admits and current individuals per set regulations. Monthly chart audits by Quality Management will identify if any information is missing. In addition, a new participant checklist will be used to capture required information for the individual's file. 01/31/2020 Implemented
2380.173(1)(iii)Primary Language not listed in Individuals #1, and #2's records at inspection.Each individual's record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English.Intake and or Program Specialist will review along with management the importance of capturing the mandated demographic information of new admits and current individuals per set regulations. Monthly chart audits by Quality Management will identify if any information is missing. In addition, a new participant checklist will be used to capture required information for the individual's file. 01/31/2020 Implemented
2380.173(1)(iv)Religious Affiliation was not listed in Individuals #1, #2, and#3's records at inspection.Each individual's record must include the following information: Personal information including: Religious affiliation.The Program Specialist/ Intake Specialist will be retrained on what information should be obtained and maintained for new participants and or current participants. The Quality Management and Compliance team will work along with the Program Specialist to audit and correct/add any missing information such as religious affiliation. Routine Chart audits of no less than on a monthly basis will help ensure compliance. 01/31/2020 Implemented
2380.173(1)(v)No current dated photos found in Individual's #1, #2, and #3's records at inspection.Each individual's record must include the following information: Personal information including: A current, dated photograph.Per regulations, the files of each individual should include a current dated photograph. The Program Specialist along with the Quality Management and Compliance Team will audit each individual file to ensure compliance with the above regulation. Also, the team will attempt to take any photos of participants that do not have them in their files, obtain the necessary consent forms, etc. A new participant checklist and routine file audits of no less than monthly will be implemented to ensure compliance. 01/17/2020 Implemented
2380.181(a)There was no initial assessment completed within 60 days of admission into the program for individual#3 on 1/2/19. The assessment dated 10/3/19 was the only annual assessment on file.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.Program Specialist along with the Compliance/Quality Management team will be retrained on the proper steps that should be taken for proper completion of documentation including signing and dating documentation and honoring set timelines. The Quality Management and Compliance Team will conduct routine audits of new participant files to ensure that documents have the acceptable signatures and are completed within set timelines to ensure compliance. The implementation of a new participant checklist will identify if compliance is being attained per ODP guidelines regarding participant documentation/files/charts 01/31/2020 Implemented
2380.181(d)The Program Specialist did not sign the Assessment dated 07/16/19 for individual #1 The Program Specialist did not sign the Assessment dated 6/20/19 for individual#2. The program specialist did not sign the assessment dated 10/3/19 for individual#3. Signature was printed.The program specialist shall sign and date the assessment.Program Specialist along with the Compliance/Quality Management team will be retrained on the proper steps that should be taken for proper completion of documentation including signing and dating documentation. Going forward, the Quality Management and Compliance Team will audit participant files to ensure that the documentation is properly completed and or submitted. Routine audits will be completed no less than monthly and or as new participants are admitted to the Program. The PS will be retrained on the above no later than 1/31/20. 01/31/2020 Implemented
SIN-00160275 Unannounced Monitoring 07/19/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)The mat in the bathroom was worn, torn and brown stains on the exposed area of the mat.Clean and sanitary conditions shall be maintained in the facility.Program management discarded the mat in question and replaced it with a new more suitable floor mat. Program management and maintenance department will conduct routine checks of the building to ensure that its condition is both clean and sanitary at all times. 09/13/2019 Implemented
2380.57A light bulb was missing from the hallway light fixture creating dim conditions near the gym.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.The maintenance department was tasked to replace the bad light bulb with a bright operable light bulb. Both the maintenance department and program management will assess building conditions on a weekly basis to ensure compliance and the health and safety of individuals-served. 09/13/2019 Not Accepted
2380.58(a)Paint was peeling from the walls in the men's and women's restrooms.Floors, walls, ceilings and other surfaces shall be in good repair.Maintenance department has been tasked to repaint/repair the walls in both the men's/women's restrooms to ensure compliance with set regulations. The Maintenance department will conduct routine checks (monthly) to ensure that all walls within the facility are in good repair and if not make the necessary repairs to ensure compliance. 09/13/2019 Implemented
2380.58(b)The floor tiles in the hallway were damaged. There were two wires that were connected to an outlet, and they were laying on the floor, which could pose a tripping hazard.Floors, walls, ceilings and other surfaces shall be free of hazards.Maintenance department was tasked to repair the floor as needed. The two wires were also removed to minimize and or eliminate the possibility of anyone falling or tripping. Program management/ maintenance department will conduct routine (monthly) checks of the facility to ensure that floors, walls, ceilings, and other surfaces are non-hazardous 09/13/2019 Implemented
2380.67(a)The furniture (chairs/sofas) were damaged in the lobby area, and another area in the program near the nurse's office. Exposed wires from the heater, located behind the desk, in the Economic Room poses unsafe conditions and constitutes a fire safety hazard. Two green sitting chairs in the music room were stained/ soiled, likely spills that were never cleaned. The stains covered the entire seat of the chairs. No odor exists.Furniture and equipment shall be nonhazardous, clean and sturdy.Program Management/Maintenance Department will discard or repair any damaged furniture and purchase suitable furniture as needed. Program management/maintenance department will also perform routing (monthly) checks of all furniture and equipment to ensure compliance and also the health and well-being of persons-served. 09/13/2019 Not Accepted
2380.70(b)A thermometer, scissors and tweezers were not included in the first aid kit.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.Program management will purchase the necessary items to ensure that the first aid kit is in compliance with set regulations. Program managers will also conduct routine assessments to further ensure compliance. 09/13/2019 Not Accepted
2380.82A bookcase stored behind the classroom door, that was adjacent to the music room, prevented entrance and departure from the room. .Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Program Staff/Maintenance Department will ensure that all doorways, halls, stairways, passageways and exits are unobstructed to prevent any injury to individuals-served and ensure their health and safety 09/13/2019 Implemented
SIN-00156361 Renewal 06/03/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff members #1,2,3,4,5,6 Pennsylvania criminal history check were not completed within the regulated timeframes.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.As a part of the new-hire orientation process and corresponding new-hire checklist, each staff person will be vetted to ensure that the meet the necessary qualifications requirements for employment. Mandatory background checks will be performed to confirm the eligibility or not of a new-hire. This process will take no longer than the first five days after the staff¿s date of hire. Routine checks no less than per new-hire/monthly, per the Quality Management department will ensure compliance with this regulation. 07/01/2019 Implemented
2380.20(b)Staff members #1,2,4,5,6,7,8,9 did not have a signed statement if they lived in the state of Pennsylvania for the past 2 years, as a result, FBI checks were not completed for these staff members.If a prospective employee who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.As a part of the new-hire orientation process and corresponding new-hire checklist, each staff person will be vetted to ensure that the meet the necessary qualifications requirements for employment. Mandatory background checks will be performed to confirm the eligibility or not of a new-hire. Routine checks no less than per new-hire/monthly, per the Quality Management department will ensure compliance with this regulation. 07/01/2019 Not Implemented
2380.36(b)CEO (staff member #10) did not complete 24 hours of annual training for the training year July 1, 2017- June 30, 2018The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Training Manager will schedule trainings for the CEO/Executive Director and other staff to ensure the required amount of training per annum. The Quality Management team, will perform monthly checks of the training schedule/spreadsheet to track compliance throughout the training calendar year. 07/01/2019 Implemented
2380.36(e)Staff members #4 and #6 did not complete fire safety training before working with individuals.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 of the local fire department as soon as possible after a fire is discovered.As a part of the new-hire orientation process and corresponding new-hire checklist, each staff person will receive Fire Safe training and any other required training prior to working with individuals served. routine checks no less than per new-hire/monthly, per the Quality Management department will ensure compliance with this regulation. 08/05/2019 Implemented
2380.36(g)At inspection it could not be determined the CPR/First Aid trainer's certification.There shall be at least one staff person for every 18 individuals, with a minimum of two staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.During the scheduling process for First Aid/CPR, management will vet that the trainer is properly certified. In addition, management will retrieve a copy of the trainer¿s certification/license for the agency¿s records 08/05/2019 Implemented
2380.58(a)At inspection, the sink in the women's bathroom in the basement area would not release the water.Floors, walls, ceilings and other surfaces shall be in good repair.AEAF¿s Maintenance Department, will check all sinks in the building to ensure proper function. Maintenance requests will be submitted to the Maintenance department as needed and repairs will be required to be completed within 3-5 days. Repairs of a severe nature will be fixed immediately. Management will perform routine checks, no less than weekly, of the edifice to ensure the safety and well-being of individuals-served, staff and visitors. 07/01/2019 Implemented
2380.69(e)At inspection, there were no paper towels in the women's bathroom in the basement areaEach bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.Plan of Correction: AEAF¿s Housekeeping department/Management will perform daily checks of bathrooms/workspaces/eating areas, etc. to ensure that the necessary toiletries are present. 08/05/2019 Implemented
2380.91(a)Individual #2's fire safety training was not included in the record.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.Program Specialist/Intake Staff in accordance with AEAF¿s new-admission process will ensure that each individual receives fire safety training within their first five days attending the program and that the training is properly documented and filed in their chart. A new-admission checklist and routine checks no less than per admission/quarterly, per the Quality Management department will ensure compliance with said regulation. 08/30/2019 Not Implemented
2380.111(c)(4)Individual #1's Annual Physical Exam dated 3/14/19, the Vison and hearing screening, was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialist will ensure that all pertinent medical information of the individual-served in captured in the individual¿s documentation. Quality Management will perform ongoing chart audits to ensure that documentation is fully and correctly completed per regulations. 08/30/2019 Not Implemented
2380.111(c)(10)Individual #2's Annual physical exam dated 9/25/18 did not include Information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist/Intake Staff will ensure that admission/related documentation identifies medical information pertinent to diagnosis and treatment in case of an emergency of each individual served. Routine chart audits, no less than quarterly/per admission by the Quality Management team/Program Specialist should minimize non-compliance in this regard. 08/05/2019 Not Implemented
2380.113(a)At inspection no physical exam could be found for staff member #4 and it could not be determined if the individual is free of communicable diseases.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.Hiring Manager in collaboration with the Quality Management team will per the agency¿s new-hire checklist and routine audits, no less than quarterly, ensure that each employee has an up to date physical exam /Mantoux test per regulations. Health Documentation will specify that staff person is free of communicable diseases and able to work with individuals-served. Quality Management team will ensure that the established timelines for physicals, etc. will be followed to ensure compliance. 08/05/2019 Implemented
2380.173(1)(ii)At inspection individuals #1 and #2's record did not include weight, height, race, hair color, eye color, 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.Program Specialist/Intake Staff will ensure that admission/related documentation identifies demographic/physiological information of each individual served. Routine chart audits, no less than quarterly/per admission by the Quality Management team/Program Specialist should minimize non-compliance in this regard. 08/05/2019 Implemented
2380.173(1)(iii)Individual #2's primary language was not included in the record.Each individual's record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English.Program Specialist/Intake Staff will ensure that admission/related documentation identifies the language or means of communication of each individual served. Routine chart audits, no less than quarterly/per admission by the Quality Management team/Program Specialist should minimize non-compliance in this regard. 08/05/2019 Implemented
2380.173(1)(iv)Individual #1 and #2's record did not include Religious affiliation.Each individual's record must include the following information: Personal information including: Religious affiliation.Program Specialist/Intake Staff will ensure that admission/related documentation identifies the religious affiliation of each individual served. Routine chart audits, no less than quarterly/per admission by the Quality Management team/Program Specialist should minimize non-compliance in this regard. 08/05/2019 Implemented
2380.173(1)(v)Individual #1 and #2's record did not include a current, dated photo.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.AEAF, will ensure that individual¿s/their parents/guardians provide written consent to the agency and will also ensure that the each individual has a current (no more than 2yrs old) taken and filed in their chart per regulations. Routine chart audits, no less than quarterly/per admission by the Quality Management team/Program Specialist should minimize non-compliance in this regard. 08/05/2019 Implemented
2380.177A consent for release of information was not included in individual #1 and #2's records.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.Upon admission, AEAF management, will ensure that individuals/their parents or legal guardians provide the agency with written consent regarding release of information; including photographs, etc. As a part of the admission process, a checklist will be used to track sign-offs such as consent. The Quality Management team will vet the process to ensure compliance. 08/30/2019 Implemented
2380.181(a)An initial assessment was not completed for individual #1 and #2.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.The program specialist will be retrained on completing re/assessments by the established timelines. Routine chart audits via quality management department will ensure compliance with set regulations. 08/30/2019 Not Implemented
2380.182(d)(1)The annual Individual Support Plan (ISP) could not be found for individual #2.The plan lead shall develop, update and revise the ISP according to the following: The ISP shall be initially developed, updated annually and revised based upon the individual's current assessment as required under § §  2380.181, 2390.151, 6400.181 and 6500.151 (relating to assessment).Program Specialist/Plan Lead will employ proper scheduling to ensure compliance with established timelines related to ISP¿s. In addition, the revision, updating, and initial development will be based on the individual¿s current assessment. AEAF¿s Quality Management Team will perform routine checks, no less than monthly, to gauge compliance 08/05/2019 Not Implemented
2380.182(d)(4)Individual #1's record, the invitation letter could not be found.The plan lead shall develop, update and revise the ISP according to the following: An invitation shall be sent to plan team members at least 30 calendar days prior to an ISP meeting.The Program Specialist will retrieve a copy of the ISP invitation letter and file it in the individual's file. Going forward, the practice will be to ensure that all invitation letters are stored in individual files. Routine chart audits via the quality control department will ensure compliance. 08/30/2019 Implemented
SIN-00139569 Unannounced Monitoring 08/07/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff person #1 and staff person #2 records did not include evidence of criminal history record checks.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.All staff files are being reviewed for necessary evidence of background checks which are required by AEAF at the onset of employment with our company. Filing system will be revamped to assure continuity of records and to receive any missing documentation. This system will continue as to not have missing information in the future. A evaluation of the nature of the crime; · The facts surrounding the conviction; · The time elapsed since the conviction; · Evidence of the employee's rehabilitation since the conviction; and · The nature and requirements of the employee's job duties. Following completion of the above, American Emerald will make a decision about whether to retain the employee, in consultation with legal counsel as appropriate. [Add to plan by ODP 10/5/18] 09/07/2018 Not Implemented
2380.32(b)(3)Staff Person #2 did not have a Pennsylvania criminal history check completed prior to hire and was completed on 9/18/18, which they had felony convictions that if you had been aware of prior to hire to assist in a determination about the person's qualification for employment.The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Safety and protection of individuals.Staff person #2 is no longer employed by AEAF, as of October 17 3. Policy/Procedure Background Checks (criminal history, child abuse, FBI) Consistent and non-discriminatory pre-employment, background checks are part of the hiring process for the AEAF employees. A pre-employment background check for employment is done to comply with pertinent laws, promote a safe work environment, to protect the AWAF's assets, including its employees, property, and information, as well as to assist departments in their hiring decision. For all non-temporary positions, any person being offered employment by the AEAF shall have all relevant academic and /or professional credentials, work history, and references, verified by a search committee or their designee. Hiring manager will be responsible for all degree verifications. In addition, for those positions designated to require a background check as described below in this policy, the check shall be completed post offer. All offers will be contingent upon the completion of satisfactory relevant background check(s) are satisfactorily completed. Background checks shall include verification of age (all employees must be 18 years of age or older to be considered for employment), criminal records, child abuse records (if necessary), FBI, (if out-of-state resident) motor vehicle operator license validation (if applicable). Hiring manager shall maintain a list of all designated positions requiring more than the minimum verification of credentials, work history and PA criminal background check. Search processes will include appropriate measure to notify candidates of background checking requirements. Once an employment offer has been notified and accepted by a candidate, the hiring manger will request a PA Background report or AEAF shall initiate the background check with the selected background check vendor. AEAF will contact the candidate to obtain consent and all appropriate information to begin the background check. If the candidate does not consent than the offer of employment must be withdrawn. The HR Director shall review all information received in conjunction with a criminal, credit history, motor vehicle operator license validation, and/or child abuse record background checks(s) and determine if the candidate is in accordance with the Older Adults Protective Services Act (35 P. S. $$ 10225.101- 10225.5102) and 6 Pa. Code Chapter 15 (relating to protective services for older adults). If no record exist the Hiring Manager will present to the CEO that the candidate is "acceptable," in which case the hiring process moves forward, or "unacceptable," in which case the finalist is disqualified from further consideration or is considered for provision work status; Policy for Provisional Employment AEAF will review candidates on a provisional basis for those that have requested a State Police criminal history record, and it has not returned at the start of work date. Conducted for a single period not to exceed 30 days and for a single period not to exceed 90 days for candidates requesting a Federal criminal history record, if all of the following conditions are met: a. Candidates shall have applied for a criminal history report and provided the facility with a copy of the completed request forms. b. The facility can attest that AEAF has no knowledge about the candidate that would disqualify the candidate from employment under 18 Pa.C.S. § 4911 (relating to tampering with public record information). c. The candidate shall swear or affirm in writing by signing a Provisional Employment Disclosure Statement that the candidate is not disqualified from employment under guidelines of the previously state code. d. The provisionally employed candidate shall receive an orientation which provides information on policies, procedures and laws which address standards of proper care and recognition and reporting of abuse or neglect, or both, of recipients. Also complete all required new hire training requirements. 10/10/2018 Not Implemented
2380.35(e)Staff Person #1 and staff person #3 were working with one individual #1 who is authorized to receive enhanced services, did not have evidence of required degrees/certification in the personnel file.The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c).Staff have completed certification training per the requirements for community participation support for direct care workers. A copy of the certificate will be sent to compliance office by email. 09/21/2018 Not Implemented
2380.36(a)Staff records did not include evidence of orientation.The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.All staff files are being reviewed for necessary evidence of orientation. Filing system will be revamped to assure continuity of records and to receive any missing documentation. This system will continue as to not have missing information in the future. 08/31/2018 Implemented
2380.36(h)Training records did not include training content.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.All staff files are being reviewed for necessary evidence of training completions, hours and standard requirements. Filing system will be revamped to assure continuity of records and to receive any missing documentation. This system will continue as to not have missing information in the future. 08/31/2018 Implemented
2380.52(a)Sensory Room on 1st floor -- 4 individuals and 5 staff were in the room. 2 staff were dedicated to 1 individual. The space did not seem to exceed 10'x12' area. There was only 1 table. The room is too small for this many people. Area for 4 people would need to be 200 square feet (50 sq. feet per person).There shall be at least 50 square feet of indoor floor space for each individual. Indoor floor space shall be measured wall to wall, including space occupied by equipment, temporary storage and furnishings. Space occupied by lavatories, dining areas, loading docks, kitchens, offices and first aid rooms may not be included unless it is documented that the space is used for programming for at least 50% of each program day. Hallways and permanent storage space may not be included in the indoor floor space.Sensory area schedule has been revamp to make sure that there are the ratio to size of the room at 400 sq feet and we will not be exceeded. We will continue to work in accordance to regulations in this matter 08/17/2018 Implemented
2380.53(a)In the basement there were cleaning supplies and other industrial solvents (including paint thinner) not locked and accessible to individuals.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Mechanical areas have been clean and any construction chemicals have been removed from the premises. All cleaning product have been moved to designated lock storage areas out of reach of individuals. Off limit areas have been identified and inspected to assure that there are no hazards present. 08/13/2018 Implemented
2380.55(a)The basement men's and women's bathrooms were stained and unsanitary.Clean and sanitary conditions shall be maintained in the facility.Floor tiles have been completely removed and new tile flooring have been replaced. New edging has been placed around the edges of the bathroom walls, cabinets have been removed and replaced to not allow any access or cracks. New floor provides a seamless flow to walls. In the future, walls will be painted. All urinals and toilet will be cleaned and sanitized. Toilet paper and hand towel dispensers will always have a supply of tissue. Hand soap dispensers will be labeled and keep full for use. Cleaning company will maintain and monitor sanitation of all bathroom areas as to mitigate uncleanness. Renovation to be complete by Sept. 07, 2018 09/07/2018 Implemented
2380.55(b)There was evidence of mouse droppings in the kitchen area.There may not be evidence of infestation of insects or rodents in the facility.Upon our inspection were not able to account for and infestation of rodents in our facility. As in all building in the city limits we did notice the dropping in that corner near an opening in the wall has since covered the one whole and have done a complete inspection to assure that the presence of any rodents has been cleared. We also cut the back land area for assure that that the field mice would not be an issue. We will continue to stay on top of the situation by continuously checking for any droppings 08/17/2018 Implemented
2380.55(d)Trash in the kitchen/dining area was not in a covered receptacle that prevents the penetration of insects/rodents.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.All trash cans in the facility will be replaced with covered lids. All trash will be continue to be removed at the end of the day as to not attract in unwanted rodents. 08/24/2018 Implemented
2380.55(e)There was a large amount of trash on the ground by the back door.Trash outside the facility shall be kept in closed receptacles that prevent the penetration of insects and rodents.The back area has been cleaned and staff have been assigned to monitor and clean this area. Cleaning staff will preform a through cleaning weekly to insure all trash has not accumulated in this area. 08/08/2018 Implemented
2380.56In the kitchen/dining area and other program areas there was mechanical ventilation (fan), but no air conditioning and or exhaust. It was very warm (95 degrees outside).Program areas, dining areas, kitchens, bathrooms and first aid rooms shall be ventilated by operable windows or mechanical ventilation such as fans or air conditioning.New wall air conditioners have been added to each program room. Added to the lunch room area, and the lobby area in order to provide a cooler atmosphere for both the individuals and the staff that care for them. Inside temperature will be maintained at between 68- and 72 degrees. Individual rooms have separate controls if more or less air is needed. Air conditioning and ventilation will be maintains as a constant, in order to provide services at a comfortable health temperature. 08/13/2018 Implemented
2380.58(a)The first floor thermostat was detached and hanging from the wall.Floors, walls, ceilings and other surfaces shall be in good repair.Older thermostat device has been removed and wall plate has been placed over opening. In the future heating system devices will not be placed in corridor areas. 08/12/2018 Implemented
2380.58(b)The dining area floor covering was joined by metal edging. Part of the edging was lifted up and sharp to the touch. The ceiling in the basement computer room had a 2'x2' tile that was detached from the grid and in danger of collapse. In the music room the internet connection wire was loose and not tacked down causing a trip hazard.Floors, walls, ceilings and other surfaces shall be free of hazards.Tile in computer room has been replaced and secured into its holding position. Metal edging has been flattened to meet evenly with each side. Floor edging will be maintained and monitored by maintenance staff to insure future safety. 08/12/2018 Implemented
2380.63(a)The back door was kept open with no screen.Windows, including windows in doors, shall be screened when windows or interior doors are open.Will install a magnetized hanging screen door that is able to open and close when individuals enter back door area. Screen will allow fresh air to enter will stopping and unwanted insects. Doors will only be opened when individuals are leaving or arriving. Future maintenance of screen door will be keep to alleviate any openings or tares. 08/31/2018 Implemented
2380.64(a)The back stairway to the basement had a handrail that was 5' short of the top of the stairway. Danger of losing balance is great.Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.Back staircase railing has been replaced to reach top of stairs to create a safe access at top of stairs. Bending to reach rail is no longer an issue. Building maintenance will continue in building in order to foresee and alleviate all hazards 08/12/2018 Implemented
2380.69(e)The basement bathrooms had no covered trash receptacle, paper towels or toilet paper. The upstairs bathroom had no paper towels or paper towel dispenser.Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.As of August 15, 2018 all bathrooms have wall mirrors, soap filled dispensers and all paper towel wall units are fill with the proper style of paper towel. Brand new trash cans have been placed in all bathrooms as well. Bathrooms are checked twice a day once by maintenance and once by the floor manager and results kept in a bathroom check log. 08/15/2018 Implemented
2380.72(a)The rear door ramp had significant play when walked upon. There were no handrails installed or other support in place.Outside walkways shall be free from ice, snow, obstructions and other hazards.As of August 12, 2018 the ramp has been fortified with cement and the "dip" has been removed. We currently contract with 2 vendors who remove snow and leaves in adverse weather. Handrails will be installed by Sept 7, 2018 as to provide added safety when walking up the ramp especially in times of inclement weather. 09/05/2018 Implemented
2380.121(b)There were non-prescription medications kept in an unlocked first aid kit in the basement.Prescription and nonprescription medications shall be kept in an area or container that is locked.As of August 12, 2018 all first aid cabinets containing non-prescription medication have had padlocks installed. Keys are stored in the key closet. General First Aid kits not containing any medicine has also been made available. 08/12/2018 Implemented
2380.132(2)Menus were not posted for the next menu date.If the facility provides or arranges for meals for individuals, the following requirements apply: Menus shall be posted at least 1 program day prior to the menu date.AEAF will post menus in the dining area as well as send weekly menus home/residential group home; allowing the individuals opportunity to bring in lunch if they so desire. 08/24/2018 Implemented
2380.132(6)The lunch that was served included turkey franks, beans, corn and bread. This does not include the required dairy, fruit and vegetable food groups.If the facility provides or arranges for meals for individuals, the following requirements apply: Each meal served shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless medically contraindicated for an individual.AEAF uses Reach for the Stars Incorporated for our meals. We will reach out to the director of that program regarding concerns about the a better section in the all the food groups. Suggestions will be made to provider to better meet these food needs 08/31/2018 Implemented
2380.132(8)Individual #2's ISP indicates that they should receive a mechanical soft diet. Staff at the facility told ODP and IDS staff that this individual is fed a regular diet according to what was told to them by residential staff from this individual's residential provider.If the facility provides or arranges for meals for individuals, the following requirements apply: A prescribed diet for an individual with a medically restricted diet shall be followed. A written record of the prescribed diet shall be kept.The individual will have the option to receive the food that AEAF provides which will be blended to adhere to the mechanical soft diet. Also AEAF will provide the individual with a weekly menu so that she/family/staff can choose her meals. This meal prep will be monitored by supervisory staff to assure that preparation to all necessary standards have been met. Individual binders have been prepared for the client/staff to have at hand during Day Program hours. Staff will be required to follow strict instruction for food texture according to ISP and will not except any changes except though relay through the ISP. 08/15/2018 Implemented
2380.132(10)In the dining area, there was a refrigerator that was used to store drinks. Some of these drinks were past the expiration data (including Ensure) and the refrigerator did not have a seal, causing it to be warm. There were dead insects at the bottom of the refrigerator.If the facility provides or arranges for meals for individuals, the following requirements apply: Food shall be protected from contamination while being stored, prepared, served and transported. Food shall be stored in sealed containers.The small refrigerator has been removed. A new large refrigerator will be placed in lunch area by Friday, August 25, 2018. As of August 10, 2018 and every subsequent Friday, the refrigerator will be cleaned. Each day, all dates on food items will be checked. Opened and expired foods will be thrown away. 08/25/2018 Implemented
2380.185(b)Individual #2's ISP indicates that they should receive a mechanical soft diet. Staff at the facility told ODP and IDS staff that this individual is fed a regular diet according to what was told to them by residential staff from this individual's residential provider.The ISP shall be implemented as written.AEAF is severing individual mechanical soft foods. The individual will have the option to receive the food that AEAF provides which will be blended to adhere to the mechanical soft diet. Also AEAF will provide the individual and their family with a weekly menu so that she/family/staff can choose her meals or bring in her meals. AEAF will also post written notice of individuals particular dietary needs in dining area. A binder has been prepared for the client/staff to have at hand during Day Program hours. 08/21/2018 Implemented
SIN-00125351 Renewal 11/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)In the sensory room by the door leading to the office there was an exposed wire.Floors, walls, ceilings and other surfaces shall be free of hazards.On December 11, 2017 in the sensory room by the door leading to the main office., the exposed wire has been covered by our maintenance team , to prevent this from happening in the future a monthly walk through of the building will be conducted by AEAF's maintenance team and management to assure that there are no wires on floors, walls, ceilings and any other surface. All areas will be free of hazards. 12/12/2017 Implemented
2380.84There is no fire safety inspection for 2017.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.An annual Fire safety inspection was completed on November 16, 2017 by Cintas . The certificate and results of the inspection is posted at the Center and a copy has been forwarded to our 2380 inspector James Richards. To prevent this from moving forward, the office manger will assure that an annual Fire safety inspection is ordered and completed on an annual bases. 11/16/2017 Implemented
2380.111(c)(3)Individual #2's physical dated 4/21/17 did not have immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.On December 8, 2017 Individual #2 Immunization record was attached with a separate form to the physical dated 4/21/2017 by AEAF Program Specialist . To prevent this from occurring in future , review of all physicals for completion will be done prior to attending the program. If a separate form is used for immunization record the form will to attached to the physical. 12/08/2017 Implemented
2380.111(c)(5)Individual #2's physical dated 4/21/17 did not have TB test.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.On December 11, 2017 AEAF Program Specialist attached (stapled) the separate TB negative test results to individual #2 physical exam form. To assure that this will not occur moving forward all physical examinations will be reviewed by the program specialist to assure that a negative TB skin test is apparent on the actual physical exam form and if a separate document is used to indicate the negative test results that document is attached to the physical. or if positive , an initial chest X-ray with the results are noted on the physical and/or attached. to physical examination. These findings will be present at time of admission to the program. 12/11/2017 Implemented
2380.111(c)(6)Individual #1's physical dated 3/22/17 did not communicable diseases.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.On December 11, 2017 our program Specialist reviewed the annual physical dated 3/22/2017 of individual #1 and contacted the Doctors office that completed the form to update the current physical to indicate rather or not the individual has any communicable diseases and include specific precautions that shall be taken in terms of reportable diseases, infections and conditions to prevent to spread of the disease to other individuals, To prevent this omission moving forward, the Program Specialist will review all physical exam reports prior to any individual admission to the program to assure this information is present. 12/12/2017 Implemented
2380.111(c)(9)Individual #1's physical dated 3/22/17 did not contain allergies.The physical examination shall include: Allergies or contraindicated medication.On December 11,2017 AEAF Program Specialist reviewed individual #1 physical dated 3/22/2017 and contacted the Physician that completed the physical to include any allergies and /or contraindicated medication the individual has been prescribed. to prevent this omission from occurring to on any physical, our Program Specialist will assure that all physicals include this information and if not, contact the SC to provide an updated physical that does include the information prior to the individuals enrollment to the program, 12/12/2017 Implemented
2380.111(c)(10)Individual #1 and #2' physical did not include information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.One December 11, 2017, our Program Specialist reviewed the physical of Individual #1 and #2 and contacted both the Physician and the SC to request an updated physical to include information pertinent to diagnosis and treatment in case of an emergency. To prevent this omission on any physical moving forward, AEAF's Program Special while reviewing physical's prior to admission to our program and will assure that this item is indicated on all physicals. 12/12/2017 Implemented
2380.181(e)(2)Individual #2's assessment dated 9/28/17 did not include likes and dislikes.The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests.On December 11, 2017 AEAF Program Specialist reviewed assessment for individual #2 and contacted the SC to request that likes, dislikes and interests of the individual, including vocational and employment interest be included in undated assessment, To prevent this from occurring moving forward all assessment will be reviewed by Program Specialist to assure that these items are included in the assessment at time of admission to the program. 01/02/2018 Implemented
2380.183(4)Individual #1 and #2's ISP did not include supervision at program.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.On December 8, 2017 our Program Specialist reviewed ISP 's and informed the SC of the individuals that a protocol and schedule outlining specified periods of time for the individuals to be without direct supervision and also include an expected outcome that must include the current level of independence and the method of evaluation to determine the outcome.. To prevent this omission on the individuals ISP moving forward ,All ISP will be reviewed for these items and reviewed annually when the updated ISP is available. 01/02/2018 Implemented
2380.183(5)Individual #2's ISP did not include a SEEN 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.On December 8th, 2017 American Emerald Awards Program Special has contacted The SC for the individual to make sure that A protocol to address the social, emotional and environmental needs, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness are included in the ISP . To prevent for incompleteness moving forward, all ISP's will be reviewed before individuals are enrolled to insure that this information is included. 12/08/2017 Implemented
2380.183(7)(i)-- Individual #1 and #2's ISP did not include an assessment of vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.On December 8, 2017 Our program Specialist reviewed and requested the ISP to include Assessment of the individuals potential to advance in vocational programming to the individual SC . To prevent this omission in moving forward Program specialist will review all IS's , revisions and annual updates to assure this information is included and if not follow through to make sure it will be included. 01/02/2018 Implemented