| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(b) | There are no 2-year attestations for new employees asking if they have lived in the state of PA for the past two years upon hire to determine if FBI checks need to be done in addition to the PA criminal history record check. | 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. | In October 2024 the FBAC Operations Director created a Residency Attestation form for employees to attest whether they have lived in Pennsylvania for the previous two years and incorporated it into a revised hiring process. New employee Molly Dagit filled out the form (Enclosure 20b.1) as part of the revised process. Molly Dagit started October 30, 2024.
In addition, the FBAC Program Manager sent all existing employees the attestation form and received the forms back on November 1, 2024. Please see Enclosure 20b.1. All employees have lived in Pa for over two years. If any of the attestation forms indicate otherwise and the employee did not have an FBI clearance check on file, an FBI check would be initiated. |
11/01/2024
| Implemented |
| 2380.70(a) | There was no provision for the first aid area to be separated by partition or privacy screen from program areas. | The facility shall have a first aid area that is separated by partition or privacy screen from program areas. | On October 28, 2024, the FBAC Program Manager confirmed with the Haverford CREC facility manager that an adjacent, unoccupied room could be used as the first aid area. In the event of need for a first aid area, the can be quickly set up to provide privacy, separated from the program area. |
10/28/2024
| Implemented |
| 2380.70(b) | The first aid area did not contain a bed or cot, a blanket, and a pillow. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | On October 28, 2024, the FBAC Program Manager purchased a cot, blanket, pillow, complete first aid kit and stored them in the Haverford CREC facility. In the event of the need for first aid, these items are easily accessible in a room adjacent to, but private from the program. |
10/28/2024
| Implemented |
| 2380.111(a) | Individual #1 did not have a physical prior to their 1/8/24 admission date. The first physical received is dated 9/10/24. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | On October 29, 2024, the FBAC Program Manager confirmed that all members have submitted Physical Examination forms.
In addition, the FBAC CEO, Operations Director, and Development Director created the FBAC Member Intake Checklist, Enclosure 181.3, to explicitly call out the need for completed medical forms prior to joining FBAC. |
10/29/2024
| Implemented |
| 2380.111(c)(5) | There is no record of individual #1 having a TB test with a negative result prior to being admitted to the program. | 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 October 27, 2024, FBAC Program Specialist / Development Director requested Individual #1 to submit TB tests results. If their TB test results are not readily available, Individual #1 will schedule an appointment to get them no later than December 1, 2024.
On October 29, 2024, the FBAC Program Manager confirmed that 11 members have TB test results and 3 do not. For those members without TB test results, they are required to provide them by December 1, 2024. |
10/29/2024
| Implemented |
| 2380.111(c)(6) | The 6/7/24 physical for Individual #2 does not indicate if the individual is free from communicable diseases. Both the yes and no boxes were left blank on the form. | 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 October 27, 2024, FBAC Program Specialist / Development Director requested Individual #2 to submit a completed Individual Physical Examination form, including the communicable disease section, no later than December 1, 2024.
On October 29, 2024, the FBAC Program Manager confirmed that 11 members' physical examination have indicated the individual is free from communicable diseases, and 3 members left that section blank. For members with incomplete Physical Examination forms, they must submit a completed form no later than December 1, 2024. |
10/29/2024
| Implemented |
| 2380.111(c)(10) | The 6/7/24 physical for individual #2 does not include information pertinent to diagnosis and treatment in case of emergency. The area designated for this information on the physical form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On October 27, 2024, FBAC Program Specialist / Development Director requested Individual #2 to submit a completed Individual Physical Examination form, including the information pertinent to treatment during emergencies, no later than December 1, 2024.
On October 29, 2024, the FBAC Program Manager confirmed that 11 members' physical examination have filled out the section with information pertinent to emergencies, and 3 members did not. For members with incomplete Physical Examination forms, they must submit a completed form no later than December 1, 2024. |
10/29/2024
| Implemented |
| 2380.113(a) | There is no physical on file for staff #2 whose date of hire was 1/8/24. | 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. | On October 29, 2024, the FBAC Program Manager confirmed that all active staff have submitted Physical Examination forms. Staff #2 is no longer employed by FBAC. |
10/29/2024
| Implemented |
| 2380.181(a) | The assessment for individual #1 is missing acquisition of functional skills, communication, personal adjustment, and personal needs with or without assistance information. There are no details regarding progress over the last 365 calendar days to determine actual progress. | 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. | On October 30, 2024, the FBAC Program Specialist conducted assessments of two new members (individuals), Enclosures 181a.1 and 181a.2. These individuals started with FBAC on September 6, 2024. The assessments were conducted within the 60 day window and more detailed information was provided for each individual. Subsequent annual assessments for other members will also provide detailed information. |
10/30/2024
| Implemented |
| 2380.21(u) | The individual rights for individual #1 were not reviewed upon admission on 1/8/24. They were first reviewed 9/3/24. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | On October 29, 2024, the FBAC Program Manager confirmed that all members have submitted signed Individual Rights Review forms.
In October 2024, the FBAC CEO, Operations Director, and Development Director revised the FBAC Member Intake process documentation to explicitly require the Individual Rights Review form be signed by new members prior to joining FBAC. |
10/30/2024
| Implemented |
| 2380.36(a) | There is no record of staff #1 receiving fire safety training. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | On October 30, 2024, the FBAC Program Specialist completed fire safety training.
Also on October 30, 2024, the FBAC Operations Director confirmed that all direct support staff have been trained on fire safety. |
10/30/2024
| Implemented |
| 2380.36(b) | There is no record of Staff #2 receiving fire safety training. Staff #2's recorded date of hire is 1/8/24. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | As noted above, On October 30, 2024, the FBAC Operations Director confirmed that all direct support staff have been trained on fire safety. Staff #2 is no longer employed by FBAC. |
10/30/2024
| Implemented |