| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(b) | FBI criminal history record check not completed for Staff #2 who resides in New Jersey. | If a prospective employe 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. | Staff #2 received her FBI background check on 10/18/2018. The check revealed that Staff #2 has no prior arrest data with the FBI. If the FBI check had revealed any negative results it would have resulted in immediate termination. Moving forward, Flat Iron Supports will request an FBI background check from all potential employees residing out of Pennsylvania on date of hire, and the potential employee's hiring status will be contingent on results of the check. The COO will be responsible for ensuring that these background checks are completed before new employees begin working with individuals. Staff #2's FBI results are attached as Attachment 10. |
10/18/2018
| Implemented |
| 2380.33(c)(2) | Staff #1 has a bachelor's degree but does not have experience working directly with persons with disabilities. | A program specialist shall have one of the following groups of qualifications:(2) A bachelor¿s degree from an accredited college or university and 2 years of work experience working directly with persons with disabilities. | Staff #1's position was changed to an Activity Specialist by the CEO on 10/04/2018 due to her lack of experience working with people with intellectual disabilities. All employees hired as Program Specialists as of 10/04/2018 will be required to provide documentation of their college degree (Associates, Bachelors, Masters) as well as documentation of their completion of the required amount of relevant experience (four, two, or one year, respectively). All new employees will also be required to present a resume or another form of documentation detailing any relevant experience working with the intellectually disabled population prior to being hired by Flat Iron Supports. The Administrative Director will be responsible for ensuring all relevant documentation is present and accurate prior to hiring a prospective employee as a Program Specialist. All current staff files were reviewed as well, and it was determined that one other staff member also does not meet the requirements of a program specialist due to her lack of experience working with the intellectually disabled. The CEO has changed her position to an Activity Specialist until she gains the experience needed to become a Program Specialist. |
10/04/2018
| Implemented |
| 2380.36(e) | Fire safety training conducted 10/2/18, Staff#2 date of hire was 9/24/18.
Fire Safety training conducted on 3/15/18, Staff#1 date of hire 3/12/18. | 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. | The COO and Administrative Director developed a plan as of 10/04/2018 to ensure that fire safety training is completed by all new employees prior to working with individuals. All new Flat Iron employees hired on or after 10/04/2018 will be required to complete fire safety training by Flat Iron's fire safety expert, the COO, on their date of hire along with all orientation documents and initial trainings. This will occur prior to any new employee working with individuals. All current staff files were reviewed by the Administrative Director on 10/05/2018 to determine whether any other members of Flat Iron staff were incompliant; all members of staff excluding Staff #1 and Staff #2 were trained in fire safety on their date of hire prior to working with individuals and were compliant. |
10/05/2018
| Implemented |
| 2380.111(a) | For individuals #1, #2, and #4, no physical exam was available on date of inspection. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Prior to attending Flat Iron Supports, all clients will present a completed physical examination form. This will be done at the initial intake meeting, and no new prospective client will be permitted to attend Flat Iron Supports until this information is provided. The Administrative Director is responsible for overseeing this process and of ensuring all proper documentation is present for new prospective clients. Current client files were reviewed, and the SC and SC Supervisors were contacted by the Administrative Director for those whose physicals were out of date or incomplete. Individual #4 provided a physical exam to Flat Iron Supports on 10/05/18, and Individual #2 provided a physical form on 10/12/18. Neither Individual #1, his SC agency, nor his family were able to provide a completed physical form as of 10/29/2018, but he has a doctor¿s appointment scheduled for November 8, 2018 to receive his annual physical. Due to the language barrier between Flat Iron Supports staff and Individual #4's mother (she speaks Spanish), most communication with the individual's family occurs via his SC and/or his SC supervisor. In the future, it is the Administrative Director's responsibility to ensure that the chain of command is followed when requesting physical examination forms; if the supports coordinator is nonresponsive or cannot provide the information needed, the SC supervisor will be contacted and the Administrative Director will continue moving up the chain until the information is acquired. The physical exams for Individuals #2 and #4 are attached as Attachments 4 and 5, respectively. The partial physical examination form we were able to attain for Individual #1 is attached as Attachment 6. |
10/29/2018
| Implemented |
| 2380.111(c)(7) | The physical exam for individual #3 dated 10/10/17did not include the assessment of the individual's health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Individual #3, her family, and her supports coordinator were all informed of the importance of the missing information on her physical examination form. Individual #3 received her updated physical exam on 10/24/2018 and returned her completed examination form on 10/25/2018. It is the Administrative Director's responsibility to ensure that all physical examination forms provided are completely up to date and filled out. The Administrative Director conducted a review of all current client files and has contacted the SC/SC supervisors of those who have incomplete physical forms on file. Individual #3's current physical is attached as Attachment 7, and her old physical form is attached as Attachment 8. |
10/25/2018
| Implemented |
| 2380.111(c)(10) | The physical exam for individual #3 dated 10/10/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #3, her family, and her supports coordinator were all informed of the importance of the missing information on her physical examination form. Individual #3 received her updated physical exam on 10/24/2018 and returned her completed examination form. It is the Administrative Director's responsibility to ensure that all physical examination forms provided are completely up to date and filled out. The Administrative Director conducted a review of all current client files and has contacted the SC/SC supervisors of those who have incomplete physical forms on file. Individual #3 and her family also completed an emergency medical form that designates her parents and brother as emergency contacts, and authorizes select Flat Iron Supports staff members to give medical consent in the event that none of these contacts can be reached in an emergency. This form is attached as Attachment 9. |
10/25/2018
| Implemented |
| 2380.173(1)(ii) | Individual#2's record did not contain height, weight and 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. | All client information briefs will be completely filled out by the Administrative Director. All information, including height, weight, and identifying marks will be completed. No fields will be left blank; if something is unknown or non-applicable to a client, it will be designated as such on the information brief. A copy of these briefs will be retained each client's file. The Administrative Director conducted a review of all current client information briefs and completed any fields that were left blank. In the future, these briefs will be completed by the Administrative Director directly following the initial intake meeting. Individual #2's updated information brief is attached as Attachment 3. |
10/04/2018
| Implemented |
| 2380.181(a) | No initial assessments available for individual's #1, #2, #3, and #4 on date of inspection. | 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 Specialists will conduct an initial assessment of each new client as of 10/10/2018. These assessments will be completed within the first 60 days of the client's enrollment in Flat Iron Supports' day program. These assessments will be signed by both the client and the program specialist who conducted the assessment and will be retained in the client's file. It is the Administrative Director's responsibility to ensure that these assessments are completed within the initial 60-day enrollment period and annually thereafter. Individual #2's assessment was completed on October 10, 2018 within his first sixty days and is attached as Attachment 2. |
10/10/2018
| Implemented |
| 2380.186(b) | Program specialist and individual's #1, #2, #3, and #4, did not sign and date ISP review signature sheets. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | All monthly, quarterly, and annual reports will be signed by both the client and a Flat Iron Supports program specialist beginning in October 2018. The CEO is responsible for ensuring that these reports are completed and signed at the end of each month/quarter/year. The CEO was trained on October 10, 2018 in the requirements of a signature on all progress reports/reviews and this training is attached as Attachment 1. These reports will be retained in the clients¿ files and emailed to their supports coordinators. |
10/10/2018
| Implemented |