| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(b) | All the new hires did not have a signed statement if the lived in Pennsylvania for the past consecutive 2 years, and no FBI criminal history record check's were found. | If a prospective employee who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. | During the time of licensing Staff #2 was the most recent employee with a hire date of 4/18/2018 and was a resident of Pennsylvania for the past two consecutive years as shown on her Pennsylvania Issued Identification Card. (Attachment 19) Moving forward, Center Director will ensure all new hires have a statement of proof of Pennsylvania residency for at least the last two years consecutively. If the new hire has not been a resident of Pennsylvania for at least the last two years consecutively, an FBI criminal history record check will be conducted on that individual prior to his/her date of hire. |
08/09/2019
| Implemented |
| 2380.67(a) | The Kitchen cabinet was broken and in need of repair. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The Kitchen Cabinet was repaired at time of the inspection. Please see attachment #7 and attachment #8. Staff was reminded to notify Center Director or Activity Manager immediately if they notice any furniture or equipment is not sturdy, not clean or potentially hazardous. Moving forward, Center Director or Activities Manager will conduct weekly facility checks to ensure compliance in this area. |
07/02/2019
| Implemented |
| 2380.91(a) | Individual #1's record did not have fire safety training. | 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. | Individual # 1 participated in fire safety training on 8/7/2019 outlining general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fie safe area in the event of an actual fire; member is a non-smoker.
Moving forward, Center Director or Nurse Manager will ensure fire safety training is conducted and properly documented upon admission and at the required periodic intervals. |
08/07/2019
| Implemented |
| 2380.111(c)(3) | The physical exam dated 4/19/19 for individual #1 did not include immunizations. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1 has an appointment scheduled for 10/17/2019 to complete documentation of their immunizations. This is the soonest appointment they were able to obtain.Moving forward, Center Director or Nurse Manager will ensure all physical exams include immunizations and it is on the correct form. Please see attachment #5. |
10/17/2019
| Implemented |
| 2380.111(c)(4) | The physical examination dated 4/19/19 for individual #1 did not include vision and hearing screenings. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Individual #1 has an appointment scheduled for 10/17/2019 to complete documentation of their vision and hearing screenings. This is the soonest appointment they were able to obtain. Moving forward, Center Director or Nurse Manager will ensure all physical exams include vision and hearing screenings and it is on the correct form. Please see attachment #5. (This form is blank as we have not had a new admission since the inspection so we do not have a completed form to submit yet |
10/17/2019
| Implemented |
| 2380.111(c)(6) | individual #2's physical exam dated 6/13/19 did not include if the individual was free of a serious communicable disease it was left blank. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals. | Individual #2 began residing in New York with his family, and was no longer a Member here to be able to update their documentation. Moving forward, Center Director or Nurse Manager will ensure all physical exams include that the individual is free of a serious communicable disease. Please see attachment #5. (This form is blank as we have not had a new admission since the inspection so we do not have a completed form to submit yet |
07/17/2019
| Implemented |
| 2380.111(c)(7) | The physical exam for individual #1 dated 4/19/19 did not include an assessment of the individuals health maintenance needs. | 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. | Individual #1 has an appointment scheduled for 10/17/2019 to complete documentation of their immunizations. This is the soonest appointment they were able to obtain. Moving forward, Center Director or Nurse Manager will ensure all physical exams include an assessment of the individuals health maintenance needs . Please see attachment #5. (This form is blank as we have not had a new admission since the inspection so we do not have a completed form to submit yet) |
10/17/2019
| Implemented |
| 2380.111(c)(10) | The physical exam for individual #2 did not include medical information pertinent to diagnosis in case of an emergency, it was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #2 began residing in New York with his family, and was no longer a Member here to be able to update their documentation. Moving forward, Center Director or Nurse Manager will ensure all physical exams include medical information pertinent to diagnosis and treatment in case of an emergency and it is on the correct form. Please see attachment #5. (This form is blank as we have not had a new admission since the inspection so we do not have a completed form to submit yet |
07/17/2019
| Implemented |
| 2380.36(b) | Staff members#1 and #2 did not have record of receiving annual fire safety training 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). | Center Director scheduled Fire Safety Training with a Certified Fire Protection Specialist on 9/20/2019 for staff at Active Day Northeast where they were instructed in smoke detector maintenance, duties during a fire drill, and the use of portable fire extinguishers (attachments 14-18). |
09/20/2019
| Implemented |
| 2380.36(c) | Staff members #1 and #2 did not have record of receiving training in CPR/First Aid, and Heimlich techniques within the past year. | There shall be at least 1 staff person for every 18 individuals, with a minimum of 2 staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification. | We respectfully request for this violation to be withdrawn as staff members #1 and #2 had CPR/First Aid and Heimlich Technique training completed. It is current and was provided to the inspector during the inspection process. Please see attachment #3 and attachment #4.
Moving forward, the Center Director will ensure all new employees either have or receive CPR/First Aid and Heimlich Technique training in a timely fashion and the records are readily available. |
07/02/2019
| Implemented |
| 2380.39(a)(3) | Staff member #1 record did not have 24 hours of annual training. | The following shall complete 24 hours of training related to job skills and knowledge each year: Positions required by this chapter. | There is documentation that trainings were conducted and the staff in question confirmed they attended these trainings, however the training documentation failed to note the length of time of each training. Moving forward, the Center Director will not only ensure the 24 hours of training is conducted for each employee, but will note the length of time as well as all of the other required elements for each training on the training sign-in sheet. Please see attachment #2. |
07/02/2019
| Implemented |
| 2380.181(f) | The assessment for individual #1 was not provided to the plan team 30 calendar days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | On 6/29/2019 the Program Specialist forwarded all updated assessments to the Plan Team via email (attachments 1-13). Moving forward, Center Director will ensure the Program Specialist will provide the individual's assessment to the plan team 30 days prior to the individual's meeting by monitoring the individual's assessment meeting dates to ensure compliance |
06/29/2019
| Implemented |