| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Various Cleaners and cleaning supplies were left accessible to the individuals in and nearby the program space. There was disinfectant spray, hand sanitizer and Lysol located in the bathroom and in a cabinet of the kitchenette. In addition, there were cleaners kept accessible in shared spaces such as the laundry room and gym. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | All potentially poisonous materials to be used by the Adult Life Skills Program will be kept in a locked cabinet in the Career Development Area. This cabinet may only be locked and unlocked by a staff member. Under staff supervision, clients will continue to be allowed access to these materials as is necessary for instruction (e.g., cleaning the kitchenette, using disinfectant spray on gym equipment, etc.), but will be returned to locked cabinet when not in use.
In addition, a lock will be installed on the laundry room door so that any potentially poisonous materials to be used by the Education Program (i.e., laundry detergent), will be kept behind the locked door when not in use by staff and students.
Who¿s responsible: Director of Adult Life Skills (Chris O¿Toole). |
01/31/2023
| Implemented |
| 2380.70(b) | The designated first aid area did not include a cot, blanket and pillows. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | First aid area will include a cot, a blanket, a pillow, and a first aid kit.
Who¿s responsible: Director of Adult Life Skills (Chris O¿Toole). |
12/20/2022
| Implemented |
| 2380.89(c) | Fire Drills for the months of August 2022 through December 2022 do not include the time of the drill, the amount of time it took to evacuate, the exit route used and if the fire alarm is operative. | 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. | Fire drill record and process will be modified to include the date, time, amount of time it took for evacuation, the exit route used, problems encountered, and whether the fire alarm was operative.
Who¿s responsible: Director of Adult Life Skills (Chris O¿Toole). |
01/12/2023
| Implemented |
| 2380.91(a) | Individual #1 was not instructed in fire safety training at admission.
Individual #2 was not instructed in fire safety training at 11/7/22 admission. | 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. | Individuals #1 and #2 will receive instruction in general fire safety, evacuation and fire drill procedures, including the designated meeting place outside of the building in the event of an actual fire. Smoking is not permitted at the facility.
Who¿s responsible: Director of Adult Life Skills (Chris O¿Toole). |
02/28/2023
| Implemented |
| 2380.111(a) | Individual #1 did not have a physical exam and tuberculosis test completed within 12 months prior to 9/6/22 admission. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 will be required to present proof of physical exam and results of tuberculosis test.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
02/28/2023
| Implemented |
| 2380.111(c)(5) | Individual #2's 9/14/22 physical did not include a tuberculosis test or results. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Individual #2 will be required to present proof of results of tuberculosis test.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
03/31/2023
| Implemented |
| 2380.113(a) | Staff #1 did not have a physical completed every 2 years. The physical record on file was dated for 2009.
Staff # 2 did not a physical exam in their 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 shall have a physical exam completed.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
01/31/2023
| Implemented |
| 2380.113(c)(3) | Staff #3's 10/16/21 physical did not have a statement if the staff was free from serious communicable diseases noted. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases 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, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | Staff #3 shall present proof of physical exam including a statement indicating that Staff #3 is are from serious communicable diseases. If Staff #3 has a serious communicable disease, the physician should indicate if there are any specific precautions that need to be taken to prevent the spread of the disease to individuals.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
02/28/2023
| Implemented |
| 2380.173(1)(ii) | Individual #1's record did not include race, height, weight, hair color, eye color and identifying marks.
Individual #2's record did not include race, height, weight, hair color, eye color 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. | Individual #1¿s and #2¿s record shall include race, height, weight, hair color, eye color, and identifying marks. This information shall be confirmed within physical exam.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
03/31/2023
| Implemented |
| 2380.173(1)(iv) | Individual #1's record did not include religious affiliation.
Individual #2's record did not include religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Individual #1¿s and #2¿s record shall include religious affiliation. This information shall be acquired through interview with individuals and parents/guardians.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
02/10/2023
| Implemented |
| 2380.181(a) | Individual #1 did not have an assessment completed within 1 year prior to or 60 calendar days after 9/6/22 admission.
Individual #2 did not have an assessment completed within 1 year prior to 11/7/22 admission. | 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. | Individuals #1 and #2 shall have an assessment completed.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
04/30/2023
| Implemented |
| 2380.36(a) | Staff # 2 has not been trained at the time of hire and before working with individuals in 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 o the local fire department as soon as possible after a fire is discovered. | Staff #2 shall receive training general fire safety, evacuation and fire drill procedures, including the designated meeting place outside of the building in the event of an actual fire, use of fire extinguishers, smoke detectors and fire alarms, and notification to the local fire department as soon as possible after a fire is discovered. Smoking is not permitted at the facility.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
04/30/2023
| Implemented |
| 2380.37(a) | Staff #1's record did not include the orientation, or any trainings required by regulation since the staff was hired.
Staff #2, hired on 6/1/22 has not have any orientation training completed.
Staff #3 hired 10/25/21 did not have orientation trainings in their record. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | Staff #1, #2, and #3 shall complete and provide proof of orientation and other trainings as required by regulation(s). The record shall include the training source, content, dates, length of training, copies of certificates received and persons attending.
Who's responsible: Director of Adult Life Skills (Chris O¿Toole). |
01/13/2023
| Implemented |
| 2380.154(a) | Individual #1 has a restrictive procedure and the human rights team minutes were not kept when discussed by the human rights team. | If a restrictive procedure is used, the facility shall use a human rights team. The facility may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | Human rights team meeting to be conducted to review Individual #1¿s Behavior Support Plan regarding restrictive procedure(s). If restrictive procedure is identified, human rights team to determine if restrictive procedure(s) are critical for Individual #1¿s success. If not, revision is necessary to Behavior Support Plan. Meeting minutes shall be recorded and maintained.
Who's responsible: Life Skills Coach Supervisor (Malinda Bell) |
02/17/2023
| Implemented |