| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. There was a large container of liquid antibacterial hand sanitizer on 2 of the program area tables. The back of this container recommends contacting poison control if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Hand sanitizers were removed immediately from both areas. All poisonous materials will be locked and made inaccessible to the individuals. All hand sanitizer labels will be checked to ensure it is not a poisonous material. |
12/08/2023
| Implemented |
| 2380.89(g) | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. At the time of the inspection the fire alarm was sounded, and all individuals and staff evacuated the building. All staff and individuals crowded outside the one exit door. I questioned staff where the meeting place was. The meeting place was said to be up by the tree as they pointed to a little further up the road. No staff or individuals evacuated to what was reported to be their meeting place. Staff said they did not go to that spot due to the cold weather. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Individuals and staff members will evacuate to the designated meeting place outside the building during each fire drill or when the alarm sounds. |
12/08/2023
| Implemented |
| 2380.111(c)(5) | According to records provided, Individual had a TB test with negative results completed on 1/16/2020 and not again until 9/8/22. This exceeds the two-year time requirement. | 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. | Individuals started Keystone Adult Day Care on 10/11/2021. She received the required TB test on 8/27/2021 and again on 9/6/2022. The individual is not due again for her next TB until 9/6/2024. See attached documents. |
12/08/2023
| Implemented |
| 2380.111(c)(11) | This individual #1 physical dated 4/26/23 reflects that he has no limitations or restrictions for a diet. However, his assessment reflects that he is a choking risk and requires his food to be cut into bite size pieces and requires supervision at meals. The assessment and ISP also reflect that he is on a low sodium diet. The physical does not reflect any of this information. | The physical examination shall include: Special instructions for an individual's diet. | Administration reached out to the program specialist of the group home in regards to the physical, received an email (see attached) that the individual had a swallow study completed in 2022 with no findings. The individual is not a choking risk or on any dietary restrictions. Reached out to the caseworker to update the individuals ISP as the information is not accurate. Program Specialist from KADC was directed not follow the individuals ISP for assessment and only follow what is on the physical. |
12/08/2023
| Implemented |
| 2380.181(a) | 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. Individual #2 had an annual assessment dated 9/15/22 and an up to date assessment has not yet been completed. This exceeds the annual time requirement. | 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. | A spreadsheet has been created for the program specialist to ensure all assessments are completed 60days after admissions and updated annually there after. All dated were added a calendar to keep track of the dates. Form is attached. |
12/08/2023
| Implemented |
| 2380.181(e)(13)(i) | Individual #2 had an annual assessment dated 9/15/22. Individual #3 had an annual assessment dated 12/1/22. Neither of these assessments address the progress and growth in the area of health. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health. | A new assessment form has been created to ensure all areas of the assessment especially the progress and growth of the individuals health is updated as required. New assessment form attached, |
12/08/2023
| Implemented |
| 2380.181(e)(13)(ii) | Individual #2 had an annual assessment dated 9/15/22. Individual #3 had an annual assessment dated 12/1/22. Neither of these assessments address the progress and growth in the area of motor and communication skills. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | A new assessment form has been created to ensure all areas of the assessment especially the progress and growth of the individuals motor and communication skills are updated as required. |
12/08/2023
| Implemented |
| 2380.181(e)(13)(iii) | Individual #2 had an annual assessment dated 9/15/22. Individual #3 had an annual assessment dated 12/1/22. Neither of these assessments address the progress and growth in the area of personal adjustment. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | A new assessment form has been created to ensure all areas of the assessment is completed especially the progress and growth of the individuals personal adjustment is update as required. |
12/08/2023
| Implemented |
| 2380.181(e)(13)(iv) | Individual #2 had an annual assessment dated 9/15/22. Individual #3 had an annual assessment dated 12/1/22. Neither of these assessments address the progress and growth in the area of socialization. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | A new assessment form has been created to ensure all areas of the assessment especially progress and growth of the individuals socialization is updated as required. |
12/08/2023
| Implemented |
| 2380.181(e)(13)(v) | Individual #2 had an annual assessment dated 9/15/22. Individual #3 had an annual assessment dated 12/1/22. Neither of these assessments address the progress and growth in the area of recreation. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | A new assessment form has been created to ensure all areas of the assessment especially progress and growth of the individuals socialization is updated as required. |
12/08/2023
| Implemented |
| 2380.181(e)(13)(vi) | Individual #2 had an annual assessment dated 9/15/22. Individual #3 had an annual assessment dated 12/1/22. Neither of these assessments address the progress and growth in the area of community integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | A new assessment form has been created to ensure all areas of the assessment especially progress and growth of the individuals recreation is updated as required. |
12/08/2023
| Implemented |
| 2380.38(b)(1) | The staff shall have orientation prior to working with individuals alone and with in 30 days of hire in the area of application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Staff original hire date was 10/13/2017. Agency reports that staff was out on medical leave for the years of 2021 and 2022. Agency reports that staff returned to work as of 1/1/2023. The staff did not have annual training on these topics during the time frame of 2021-2022. The staff did not have new orientation on these topics prior to her new start date of 1/1/2023. Staff had a training on Person Centered Practices on 2/6/23 and a training on Individual choice on 7/2023. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Any new or existing staff who take a leave of absence will have all required orientation prior to working with the individuals on all required training topics. |
12/08/2023
| Implemented |
| 2380.38(b)(2) | The staff shall have orientation prior to working with individuals alone and with in 30 days of hire in the area of The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations. Staff original hire date was 10/13/2017. Agency reports that staff was out on medical leave for the years of 2021 and 2022. Agency reports that staff returned to work as of 1/1/2023. The staff did not have annual training on this topic during the time frame of 2021-2022. The staff did not have new orientation on this topic prior to her new start date of 1/1/2023. Staff had a training on abuse on 3/16/23. This exceeds the time frame. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Any new or existing staff member shall be orientated to the prevention. detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adult Protective Services act prior to working with any of the individuals. |
12/08/2023
| Implemented |
| 2380.38(b)(4) | The staff shall have orientation prior to working with individuals alone and within 30 days of hire in the area of Recognizing and reporting incidents. Staff original hire date was 10/13/2017. Agency reports that staff was out on medical leave for the years of 2021 and 2022. Agency reports that staff returned to work as of 1/1/2023. The staff did not have annual training on this topic during the time frame of 2021-2022. The staff did not have new orientation on this topic prior to her new start date of 1/1/2023. Staff had a training on recognizing and reporting incidents on 4/13/23. | The orientation must encompass the following areas: Recognizing and reporting incident. | Any new or existing staff member on a leave of absence shall be orientated to recognizing and reporting a incident prior to working with any of the individuals. |
12/08/2023
| Implemented |