| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(c) | Staff #1 was hired on 2/21/22, however the most recent criminal history record check had not been completed since 6/14/2019. This exceeds the 1-year timeframe allowed prior to the person's date of hire. | Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire. | "1. Vista identified the issue in February 2023 and requested a new clearance from Staff #1. On 2/7/23, this was submitted to HR.
2. HR Manager provided additional training to HR Coordinator in February 2023 to clarify the regulatory requirments between different Vista companies.
3. HR Manager has been completing (and will continue to complete) audits of every new hire's employment file since May 2023 to prevent further errors." |
08/07/2023
| Implemented |
| 2380.61 | During the physical walkthrough it was found that the program is using is using a cellphone for use of their operable, non-coin operated phone. While, this is acceptable, the cellphone was located not on a charger. If utilizing a cellphone, it must be always placed on a charger. | The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | The cell phone has been placed on the charger in the program room. Program Manager has been retrained on regulation 2380.61. See attachment #1 and Attachment #2 Training Log |
08/07/2023
| Implemented |
| 2380.62 | The cellphone utilized as the operable, non-coin operated phone to satisfy regulation #61 was found without emergency telephone numbers posted on or by the phone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line. | The cell phone is located in the program room. The emergency numbers have been posted on the phone. Program Manager has been retrained on regulation 2380.62. See attachment #1 and Attachment #2 Training Log |
08/07/2023
| Implemented |
| 2380.173(1)(i) | Individual #1's date of admission is not listed in their record.
Individual #2's date of admission is not listed in their record. | The name, sex, admission date, birthdate and Social Security number. | Client facesheets have been updated to include their date of admission. Program Manager has been retrained on regulation 2380.173 (1) (i). Please see attachment # 2 training log, attachment #3 and attachment #4 |
08/07/2023
| Implemented |