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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(a) | Direct Service Worker # 1, date of hire 9/9/24, had a Pennsylvania criminal history record check requested 10/21/23. However, the Pennsylvania criminal history check states "Request still pending." A completed Pennsylvania criminal history record check was not provided. | 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. | DSW #1 was terminated.
The program coordinator will ensure all staff have completed a criminal background check. All clearances will be read and verified that their clearance is not "pending" and that there is a dissemination date provided. |
03/21/2025
| Implemented |
| 2380.111(c)(5) | Individual #4, date-of-admission 7/1/24, had a physical examination completed on 4/15/24. However, the physical examination completed 4/15/24 did not contain a Tuberculin evaluation. A Tuberculin evaluation included in Individual #4 record was dated 11/8/22, which exceeds 12-months prior to admission. | 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. | The program coordinator will request a current TB test and results for individual #4. |
03/21/2025
| Implemented |
| 2380.113(a) | Direct Service Worker #3, date of hire 2/6/25, had a physical examination completed on 2/7/25. This exceeds the prior to employment requirement. | 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. | All new staff shall be required to provide proof of physical examination prior to their start date in the day program. |
03/21/2025
| Implemented |
| 2380.113(c)(2) | Direct Service Worker # 1 had a physical examination dated 10/24/23. The physical indicated the tuberculin skin test was negative, but the date of the test was left blank and did not indicate which type of tuberculin skin test was performed. Therefore, compliance could not be measured. [Repeat Violation 3/12/24, et.al.] | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | Program coordinator will inspect the physical examination form to make sure what type of TB test was completed, the results, and the date the test and results were done and read respectively. |
03/21/2025
| Implemented |
| 2380.181(e)(4) | Individual # 2 current assessment, completed on 12/4/24, indicated the following regarding supervision in the community: Individual # 2 is in the community 25% of the time when participating at the facility. However, the type(s) or level(s) of supervision required (i.e.: eyesight, auditory range, arm's length, etc.) when in this setting was not addressed. Individual # 3 current assessment, completed on 2/17/25, indicated the following regarding supervision in the community: Individual # 3 is in the community 25% of the time when participating at the facility. However, the type(s) or level(s) of supervision required (i.e.: eyesight, auditory range, arm's length, etc.) when in this setting was not addressed. Individual #4 current assessment, completed on 7/29/24, indicated the following regarding supervision in the community: Individual #4 is in the community 25% of the time when participating at the facility. However, the type(s) or level(s) of supervision required (i.e.: eyesight, auditory range, arm's length, etc.) when in this setting was not addressed. | The assessment must include the following information: The individual¿s need for supervision. | The Erie office Director completed an update on the "Client Baseline Assessment and Annual Progress" form to include the supervision needs of an individual in the community, not only the facility. |
03/21/2025
| Implemented |
| 2380.181(e)(12) | Individual # 1 current assessment, completed on 1/28/25, did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. "N/A" was indicated in this corresponding field. Individual #3 current assessment, completed on 2/17/25, did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. "N/A" was indicated in this corresponding field. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The HDS Erie office Director updated the "Client Baseline Assessment and Annual Progress" form to eliminate the "write N/A if not applicable" from the form. |
03/21/2025
| Implemented |
| 2380.181(e)(14) | Individual # 1 current assessment, completed on 1/28/25, did not include or address their knowledge of water safety and ability to swim. Individual # 2 current assessment, completed on 12/4/24, did not include or address their knowledge of water safety and ability to swim. Individual #4 current assessment, completed on 7/29/24, did not include or address their knowledge of water safety and ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | An assessment of individuals 1, 2, and 4 will be conducted on their functional assessments. |
03/21/2025
| Implemented |
| 2380.21(u) | Individual #4, date of admission 7/1/24, was informed of and explained individual rights and the process to report a rights violation on 7/9/24. This exceeds the upon admission requirement. [Repeat Violation 3/12/24, et.al.] | 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 3/14 the HDS Erie office Director, PS, and program coordinator discussed documentation requirements during the intake process. The PS and/or the program coordinator shall meet with each individual the day of their admittance to ensure that their individual rights and the process to report a rights violation is relayed prior to any further participation in the program. |
03/21/2025
| Implemented |
| 2380.36(a) | Direct Service Worker (DSW) # 1 was trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility 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 the notification to the local fire department as soon as possible after a fire is discovered on 10/15/24. The first day DSW #1 worked with individuals was on 9/18/24. Fire Safety training is required prior to working with individuals. Program Specialist #2 was trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility 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 the notification to the local fire department as soon as possible after a fire is discovered on 4/15/23, and then again on 4/22/24. This exceeds the annual requirement. DSW #3 was trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility 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 the notification to the local fire department as soon as possible after a fire is discovered on 2/25/25. DSW #3's first day working with individuals was on 2/10/25. Fire Safety training is required prior to 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 o the local fire department as soon as possible after a fire is discovered. | The HDS Erie office Director created an addendum to the staff orientation checklist to include fire safety training and all evacuation policies on their start date but prior to working with individuals. |
03/21/2025
| Implemented |
| 2380.182(c) | Individual # 2 Individual Support Plan, last updated 1/9/25, was not revised to reflect their current needs as based on their current assessment, completed on 12/4/24, for fire evacuation. The ISP indicates "the individual receives assistance in all evacuation situations". However, the assessment indicates, "Individual can evacuate in the event of a fire." Individual #3 Individual Support Plan, last updated on 2/6/25, was not revised to reflect their current needs as based on their current assessment, completed on 2/17/25, in the following health and safety skill domains: regarding poisonous materials, Individual #3 Individual Support Plan stated that they most likely would ingest such substances and that poisons are kept locked at the Day Program. However, Individual #3 assessment indicated that they can independently avoid or use poisonous materials; and regarding supervision, Individual #3 Individual Support Plan explained that they require total supervision for six hours and must always be within eyesight while at the Day Program. In the community, Individual #3 also needs total supervision, but can use the restroom privately in both settings. In contrast, Individual #3 assessment informed that they require observation and monitoring at the Day Program in the forms of verbal, gestural, and modeling prompting. Individual #3 assessment went on further to indicate that they are in the community 25% of the time while participating at the facility but addressed neither the type(s) or level(s) of supervision required (i.e.: eyesight, auditory range, arm's length, etc.) when in this setting nor their supervision needs while using the bathroom in both environments. Individual #4 Individual Support Plan, last updated on 1/28/25, was not revised to reflect their current needs as based on their current assessment, completed on 7/29/24, in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #4's Individual Support Plan explained that they are able to sense such sources but require reminders to quickly move away from them. However, Individual #4 assessment indicated they can independently both sense and quickly move away from these types of heat sources; regarding fire evacuation, Individual #4 Individual Support Plan stated that they require prompting from staff to initiate evacuation in the event of a fire, while their assessment informed that they can safely do so with independence; regarding supervision, Individual #4 Individual Support Plan explained that they are "supervised according to the ratio reflected in their authorized ISP [which was not indicated] to ensure health and safety at all times" at the Day Program. In the community, Individual #4 Individual Support Plan stated that they require direct supervision, especially when around traffic. In contrast, Individual #4 assessment informed that they require observation and monitoring at the Day Program in the forms of verbal, gestural, and modeling prompting. Individual #4 assessment went on further to indicate that they are in the community 25% of the time while participating at the facility but did not address the type(s) or level(s) of supervision required (i.e.: eyesight, auditory range, arm's length, etc.) when in this setting; and regarding water safety, Individual #4 Individual Support Plan informed that they cannot regulate their own water temperature, that they need supervision when around small and large bodies of water, and that they utilize a life jacket. However, Individual #4 assessment left this skill domain unaddressed entirely. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program coordinator and the program specialist shall complete annual assessments while reading the individuals' ISPs to ensure cohesiveness. When/if our assessment of an individual differs from the ISP the PS and/or the coordinator shall ensure that our program's assessment is added to the ISP, specifically citing the difference "as seen or observed" at our facility if there is a discrepancy. |
03/21/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(c)(3) | Program Specialist #2 does not have an associate's degree or 60 credit hours from an accredited college or university and only has 2 years 7 months of work experience working directly with persons with disabilities. | A program specialist shall have one of the following groups of qualifications: An associate¿s degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with persons with disabilities. | Program specialist 2 was replaced on 3/25/24 by an interim Program specialist,. Interim Program Specialist has a Bachelor of liberal arts degree and 20 years of experience working directly with persons with intellectual disabilities. |
03/25/2024
| Implemented |
| 2380.84 | The facility did not have an annual onsite fire safety inspection by a fire safety expert in 2022 or 2023. This exceeds the annual requirement. | 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. | The office Director has scheduled an immediate fire safety inspection of the facility by the Millcreek Township Fire chief and code enforcement officer. The earliest it could be scheduled is for is 4/11/2024 at 9:30am. |
04/11/2024
| Implemented |
| 2380.89(a) | The facility did not conduct an unannounced fire drill in April 2023 [Repeat violation, 04/05/23]. | An unannounced fire drill shall be held at least once a month. | Program specialist conducted an unannounced fire drill on 5/26/23 and every month subsequently. |
05/26/2023
| Implemented |
| 2380.113(a) | Program Specialist #2, date of 08/16/21, had a physical examination completed on 04/27/22. Program Specialist #2 did not have a physical examination within 12 months prior to employment. Direct Support Professional #3, date of hire 06/13/22, had a physical examination completed on 06/20/22. Direct Support Professional #3 did not have a physical examination within 12 months prior to employment. | 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. | Program coordinator (formerly Program specialist 2) and direct support professional 3 have both gotten physical examinations on 4/27/22 and 6/20/22. |
04/01/2024
| Implemented |
| 2380.113(c)(2) | Program Specialist #2, date of hire 08/16/21, had a Tuberculin skin test completed on 04/29/22. Program Specialist #2 did not have a Tuberculin skin test completed prior to employment. Direct Support Professional #3, date of hire 06/13/22, had a Tuberculin skin test completed on 06/19/22. Direct Support Professional #3 did not have a Tuberculin skin test completed prior to employment. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | Program coordinator (former program specialist 2) and direct support professional 3 have both gotten Tuberculin skin tests on 4/29/22 and 6/19/22. |
04/01/2024
| Implemented |
| 2380.21(u) | Individual #1 was informed and explained individual rights on 10/04/22 and then again on 11/06/23. This exceeds the annual requirement [Repeat violation, 04/05/23]. | 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. | Program specialist 1 was let go due to dereliction of duties.
When PS 1 was let go the Program coordinator reviewed individual rights to individual 1 as soon as the error was caught, on 11/06/23. |
11/06/2023
| Implemented |
| 2380.36(b) | Program Specialist #2 completed annual fire safety training on 04/12/22 and then again on 05/02/23. This exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The interim program specialist reviewed annual requirements for staff with the program coordinator on 3/26/24. The program coordinator reviewed annual staff requirements for staff with the direct staff on 3/26/24. |
03/26/2024
| Implemented |
| 2380.39(c)(6) | Program Specialist #2's annual training did not include the following training topic in the 2023 annual training year, dated 1/1/23 to 12/31/23: Implementation of the Individual Plan. Direct Support Professional #3's annual training did not include the following training topic in the 2023 annual training year, dated 1/1/23 to 12/31/23: Implementation of the Individual Plan | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The CEO reviewed with the program specialist the annual training requirements on 3/26/24. The program specialist reviewed the annual training requirements with the program coordinator and direct staff on 3/26/24.
On 3/26/24 the program coordinator created a training log for all staff working directly with an individual to fill out at the time of their Implementation of the ISP training. |
03/26/2024
| Implemented |
| 2380.181(f) | Program Specialist #1 completed Individual #1's assessment on 09/07/23; however, the assessment was not sent to the plan team prior to the individual plan meeting held on 10/25/23. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Upon further investigation, the former program specialist 2 discovered that program specialist 1 did indeed send individual 1's assessment at least 30 days prior to the individual plan meeting. The assessment was sent to individual 1's individual plan team on 9/08/23 via email. Email available and can be attached as proof.
*Also, please note that the date on the Description is inaccurate-10/25/24. It was 2023. |
09/07/2023
| Implemented |
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