| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.82 | At 2:54PM, the door in the hallway of the facility that serves as a passageway way to a side exit has a turn lock posing an obstructed egress when engaged. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | In order to correct this violation, on July 31, 2024, the maintenance technician removed the turn lock from the door in the hallway that serves as a passageway way to a side exit and replaced it with a non-locking doorknob. |
07/31/2024
| Implemented |
| 2380.84 | A fire safety inspection was conducted on 2/29/2024. There was no documenation of the previous inspection; therefore, annual compliance could not be measured. | 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. | In order to correct this violation, the Maintenance Supervisor implemented a filing system on August 5th, 2024, to store and easily retrieve all fire safety inspection documentation. Additionally, Fire Safety Inspection documentation has been added to the Family Services United SharePoint, ensuring that all management employees can access and retrieve it as needed. |
08/05/2024
| Implemented |
| 2380.91(a) | Individual #1, date of admission 11/6/2023, was initially trained in fire safety on 11/13/2023. Individual #4, date of admission 11/6/2023, was initially trained in fire safety on 12/7/2023. | 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. | In order to correct this violation, the Program Coordinator created a pre-admission checklist on August 2nd, 2024. The Program Specialist was trained on this checklist and re-trained on the pre-admission process and documentation on August 5, 2024. This checklist ensures that individuals are informed of Fire Safety Protocol and Evacuation Procedures, and that signatures are obtained upon admission.
Additionally, the Program Specialist has implemented an electronic calendar system to ensure that Individual #1 and Individual #4 receive their annual training thereafter. |
08/05/2024
| Implemented |
| 2380.111(c)(4) | Individual #2's physical examination, completed on 3/21/24, did not include a vision or hearing examination. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | in order to correct this violation, the Program Coordinator created a pre-admission checklist on August 2, 2024. The Program Specialist was trained on the pre-admission checklist and re-trained on pre-admission process and documentation on August 5th, 2024. This checklist ensures that individuals Physical is completed in its entirety and includes a hearing and vision examination upon the individual's admission. |
08/05/2024
| Implemented |
| 2380.111(c)(7) | Individual #4's physical examination, completed 7/17/2023, does not include the medication regimen. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | In order to correct this violation, the Program Specialist obtained the missing medication regimen on August 5th, and the file for Individual #4 was updated accordingly. Additionally, the Program Coordinator developed a pre-admission checklist on August 2, 2024. The Program Specialist was trained on the use of this checklist and re-trained on the pre-admission process and documentation on August 5th, 2024. This checklist ensures that the individual's physical examination is fully completed and includes medication regimen. |
08/05/2024
| Implemented |
| 2380.181(e)(2) | Individual #3's assessment, completed 5/11/2024, does not include dislikes. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | To correct this violation, the Program Specialist updated Individual #3's assessment on August 2nd to include the individual's likes, dislikes and interests of the individual, including vocational and employment interests. On August 6th, the Program Coordinator created a checklist to ensure all assessments are completed thoroughly. This checklist includes a section for reviewing and documenting likes, dislikes and interests of the individual, including vocational and employment interests as part of the assessment process. Additionally, the Program Specialist was re-trained on August 6th to ensure that all future assessments are comprehensively documented. |
08/06/2024
| Implemented |
| 2380.181(e)(6) | Individual #4's assessment, completed 10/31/2023, does not include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | To correct this violation, the Program Specialist updated Individual #4's assessment on August 2nd to include the individual's ability to safely use or avoid poisonous materials. On August 6th, the Program Coordinator created a checklist to ensure all assessments are completed thoroughly. This checklist includes a section for reviewing and documenting critical safety considerations, such as the ability to handle or avoid poisonous materials, as part of the assessment process. Additionally, the Program Specialist was re-trained on August 6th to ensure that all future assessments are comprehensively documented. |
08/06/2024
| Implemented |
| 2380.181(e)(7) | Individual #4's assessment, completed 10/31/2023, does not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | To correct this violation, the Program Specialist updated Individual #4's assessment on August 2nd to include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. On August 6th, the Program Coordinator created a checklist to ensure all assessments are completed thoroughly. This checklist includes a section for reviewing and documenting knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated, as part of the assessment process. Additionally, the Program Specialist was re-trained on August 6th to ensure that all future assessments are comprehensively documented. |
08/06/2024
| Implemented |
| 2380.181(e)(9) | Individual #3's assessment, completed 5/11/2024, does not address documentation of the individual's disability, including functional and medical limitations. This section only reads, "functional and medical limitations were reviewed in the individual support plan medical information section. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | To correct this violation, the Program Specialist updated Individual #3s assessment on August 2nd to include the individual's disability, including functional and medical limitations. On August 6th, the Program Coordinator created a checklist to ensure all assessments are completed thoroughly. This checklist includes a section for reviewing and documenting disability, including functional and medical limitations, as part of the assessment process. Additionally, the Program Specialist was re-trained on August 6th to ensure that all future assessments are comprehensively documented. |
08/06/2024
| Implemented |
| 2380.181(e)(10) | Individual #1's assessment, completed 3/5/2024, did not include the individual's lifetime medical history. Individual #2's assessment, completed 3/5/2024, did not include the individual's lifetime medical history. Individual #3's assessment, completed 5/11/2024, did not include the individual's lifetime medical history. Individual #4's assessment, completed 10/31/2023, did not include the individual's lifetime medical history. | The assessment must include the following information: A lifetime medical history. | To correct this violation, the Program Specialist updated Individual #1, Individual #2, Individual #3 and Individual #4 assessment on August 2nd to include the individual lifetime medical history. On August 6th, the Program Coordinator created a checklist to ensure all assessments are completed thoroughly. This checklist includes a section for reviewing and documenting lifetime medical history as part of the assessment process. Additionally, the Program Specialist was re-trained on August 6th to ensure that all future assessments are comprehensively documented. |
08/06/2024
| Implemented |
| 2380.181(e)(11) | Individual #1's assessment, completed 9/4/2023, indicates that a psychiatric evaluation was completed on 2/14/2024 and to see attachment. The agency does not have this attachment or documentation of the psychiatric evaluation. Individual #3's assessment, completed 5/11/2024, does not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | To correct this violation, the Program Specialist updated Individual #1's and Individual #3's assessment on August 2nd to include the psychological evaluation. On August 6th, the Program Coordinator created a checklist to ensure all assessments are completed thoroughly. This checklist includes a section for reviewing and documenting psychological evaluation as part of the assessment process. Additionally, the Program Specialist was re-trained on August 6th to ensure that all future assessments are comprehensively documented. |
08/06/2024
| Implemented |
| 2380.181(e)(14) | Individual #3's assessment, completed 5/11/2024, does not address the Individual's ability to swim. Individual #4's assessment, completed 10/31/2023, does not address the Individual's ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | To correct this violation, the Program Specialist updated Individual #3 and Individual #4's assessment on August 2nd to include the individual's knowledge of water safety and ability to swim. On August 6th, the Program Coordinator created a checklist to ensure all assessments are completed thoroughly. This checklist includes a section for reviewing and documenting the individual's knowledge of water safety and ability to swim. as part of the assessment process. Additionally, the Program Specialist was re-trained on August 6th to ensure that all future assessments are comprehensively documented. |
08/06/2024
| Implemented |
| 2380.21(n) | At 2:45PM, cameras were in the program areas, hallways and outside the building. A monitor screen that was easily visible was above the reception desk displaying live video feeds of all activity throughout the building. | An individual has the right to privacy of person and possessions. | In order to correct this violation on 8/2/2024 the IT technician came and removed all the program area monitoring from the reception area. Cameras will only display footage of the parking lot and front and back doors for access control. |
08/02/2024
| Implemented |
| 2380.21(u) | Individual #1, date of admission 11/6/2023, was informed and explained individual rights on 11/13/2023. | 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. | In order to correct this violation, the Program Coordinator created a pre-admission checklist on August 2nd, 2024. The Program Specialist was trained on this checklist and re-trained on the pre-admission process and documentation on August 5, 2024. This checklist ensures that individuals are informed of their Individual Rights, and that signatures are obtained upon admission. Additionally, the Program Specialist has implemented an electronic calendar system to ensure that Individual #1 receives their annual training thereafter. |
08/05/2024
| Implemented |
| 2380.36(b) | The fire safety training completed on 4/29/2024 for Direct Service Worker #2, date of hire 4/29/2024, was not completed by a fire safety expert. The fire safety training completed on 2/23/2024 for Direct Service Worker #3, date of hire 2/21/2024, was not completed by a fire safety expert. The fire safety training completed on 1/23/2024 for Direct Service Worker #4, date of hire 1/23/2024, was not completed by a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | In order to correct this violation, on August 16, 2024, Family Services United has contracted with Cintas to provide annual Fire Safety Training with a Certified Fire Safety Expert. The Staffing Administrator will schedule Fire Safety Training with a Cintas Fire Safety Expert for all staff members by September 20, 2024. |
08/16/2024
| Implemented |
| 2380.37(a) | Direct Service Worker #2's training log includes prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse; however, there is no documentation of content, certificate of completion, or persons attending the training. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | In order to correct this violation, the Human Resources Team retrained Direct Service Worker #2, on August 7th, 2024, on the prevention, detection, and reporting of abuse, via the Relias platform, to ensure that all training sessions are properly documented with detailed records using Relias. On August 4th, 2024, the Staffing Administrator developed a checklist for Human Resources Team to ensure all initial orientation training is completed and properly documented. |
08/07/2024
| Implemented |
| 2380.38(b)(1) | Behavior Specialist #3, date of hire 2/21/2024, completed orientation training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 4/9/2024. | 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. | In order to correct this violation, the Staffing Administrator developed a checklist on August 5th, 2024, for the Human Resources team to ensure that all initial orientation training is completed and properly documented. Furthermore, the orientation training content was reorganized to prioritize the timely completion of the required initial training. |
08/05/2024
| Implemented |
| 2380.38(b)(2) | Direct Service Worker #4, date of hire 1/23/2024, completed orientation training in 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 on 3/20/2024. | 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. | In order to correct this violation, the Staffing Administrator developed a checklist on August 5th, 2024, for the Human Resources team to ensure that all initial orientation training is completed and properly documented. Furthermore, the orientation training content was reorganized to prioritize the timely completion of the required initial training. |
08/05/2024
| Implemented |
| 2380.38(b)(3) | Direct Service Worker #4, date of hire 1/23/2024, completed orientation training in individual rights on 3/20/2024. | The orientation must encompass the following areas: Individual rights. | In order to correct this violation, the Staffing Administrator developed a checklist on August 5th, 2024, for the Human Resources Team to ensure that all initial orientation training is completed and properly documented. Furthermore, the orientation training content was reorganized to prioritize the timely completion of the required initial training. |
08/05/2024
| Implemented |
| 2380.38(b)(4) | The orientation for Direct Service Worker #2, date of hire 4/29/2024, did not include recognizing and reporting incidents. Direct Service Worker #4, date of hire 1/23/2024, completed orientation training in recognizing and reporting incidents on 3/20/2024. | The orientation must encompass the following areas: Recognizing and reporting incident. | In order to correct this violation on August 5th Direct service worker#2 was trained on recognizing and reporting incidents. Additionally, the Staffing Administrator developed a checklist on August 5th, 2024, for the Human Resources Team to ensure that all initial orientation training is completed and properly documented. Furthermore, the orientation training content was reorganized to prioritize the timely completion of the required initial training. |
08/05/2024
| Implemented |
| 2380.38(b)(5) | Direct Service Worker #4, date of hire 1/23/2024, completed orientation training on job related knowledge and skills on 2/29/2024. | The orientation must encompass the following areas: Job-related knowledge and skills. | In order to correct this violation, the Staffing Administrator developed a checklist on August 5th, 2024, for the Human Resources Team to ensure that all initial orientation training is completed and properly documented. Furthermore, the orientation training content was reorganized to prioritize the timely completion of the required initial training. |
08/05/2024
| Implemented |
| 2380.39(c)(1) | Chief Executive Officer #1's training for the annual training year 7/1/2023 through 6/30/2024, did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | In order to correct this violation, on August 8th, 2024, the CEO has completed training sessions that cover person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships trainings. |
08/08/2024
| Implemented |
| 2380.182(c) | Individual #2 assessment, completed 3/5/2024, states that physical prompts are needed for safe fire evacuation. Individual #2 individual plan, last updated 5/15/2024 reads, "[Individual #2] would need full assistance when evacuating the building in the event of a fire." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | In order to correct the violation, the Program Specialist updated the assessment for Individual #2 on August 2nd to ensure it aligns with the ISP regarding fire evacuation assistance needs. The Program Specialist was also re-trained on 8/6/2024 to ensure that all future individual plans are accurately aligned with their corresponding assessments. |
08/06/2024
| Implemented |