| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Poisonous materials shall be kept locked when not in use. At the time of the inspection, program room 102 had a cabinet above the sink that contained poisons which included a disinfectant cleaner. This cabinet was not locked at the time of the inspection. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Regulation 53a. will be reviewed with ADS staff and Program Specialist by the Program Director. The retraining will occur on 12/12/24. All staff will sign the presented document and will be routinely reviewed at our monthly staff meetings |
12/12/2024
| Implemented |
| 2380.53(b) | Poisons shall be in their original labeled containers. At the time of the inspection there was a clear squeeze bottle located in the cabinet of the kitchen area containing a red liquid. It was unable to be determined what this liquid was at the time of inspection. The bottle was next to another labeled bottle which was identified as Halloween blood. There was also a small brown pump bottle at the sink which contained a hand lotion or hand soap that was not labeled. It was unable to be determined what substance was in that bottle as it was not labeled. | Poisonous materials shall be stored in their original, labeled containers. | A training was completed about not emptying any substance into another container. Everything needs to have the original label on the item. |
12/12/2024
| Implemented |
| 2380.91(a) | An individual shall be instructed in general fire safety, evacuation procedures, responsibilities during a fire drill, the designated mtg place, and smoking safety procedures if individual smoke at the facility upon initial admission and annually thereafter. I did not see documentation with fire safety in the individual record. Individual's 1, 2, 3, 4, 5, 6, 7 and 8 were missing this 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. | Each New admission will be instructed on the fire and safety procedure as specified in 91a. A copy of the fire and safety document will be placed in the client's file. The Program specialist will make a note of the date that the protocol was reviewed and will completed annually thereafter. |
12/12/2024
| Implemented |
| 2380.111(c)(6) | Individual #6 annual physical dated 3/30/24 reflects that the individual is not free from communicable diseases by checking "no" on their form. Below that area, it stated that individual is a CMV carrier. The physical did not contain any specific precautions to be taken as the form reflects, they are not free from the communicable disease, and it is important to prevent the spread of disease to other individuals. | 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. | Client N.O physical was reviewed by the Primary Physician. A statement from the Dr. was provided that staff need to utilize universal precautions when caring for the individual. |
12/12/2024
| Implemented |
| 2380.173(1)(v) | The individual record shall include a current dated photo of the individual. Individual #5 did not have a photo in his file at the time of inspection. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | Client 5 photo has been taken and submitted in the chart. This regulation was reviewed with the Program Specialist and re-training was provided on 12/12/24 by the Program Director |
12/12/2024
| Implemented |
| 2380.181(a) | Each individual shall have an initial assessment within a year prior or 60 calendar days after admission to the facility. The assessment shall be updated annually thereafter. Individual #5 had an assessment dated 8/16/23 and has not had an updated annual assessment. This exceeds the time frame. Also, Individual #6 individual had an annual assessment on 2/11/23. There was no updated assessment completed in 2024. This exceeds the annual 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. | Reg 181a was reviewed with the Program Specialist on 12/11/24. Moving forward, all assessments will be completed within the designated time frame as per regulations |
12/12/2024
| Implemented |
| 2380.21(l) | The individual has a right to make choices and accept risks. As of October 1, 2024 ODP will measure compliance of this regulation by a review documentation from that agency. The documentation should include a conversation occurring between July 1, 2024 and Sept 30, 2024 with individual, staff personnel, the date and the content of the discussion of what activities are preferred by the individual. Individual #1, 2, 3, 4, 5, 6, and 7 were missing this documentation in their file. | An individual has the right to make choices and accept risks. | The Program Specialist completes a like and dislike assessment which is developed with the client and reviewed and the ISP meeting. This is included in the individual's assessment. The Program Director will develop a separate form to include date that the discussion was held with the individual. |
12/12/2024
| Implemented |
| 2380.21(u) | The facility shall inform and explain individual rights and the process to report a rights violation to the individual and person designated to the individual upon admission and annually thereafter. Individual #2 was informed of their rights on 8/7/23 and not again until 11/6/24, this exceeds the time frame. Individuals # 5, 6, and 7 were missing this entire document in their personal records. | 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. | The individual rights form was reviewed with the Program Specialist and re-training was provided by the Program Director |
12/11/2024
| Implemented |
| 2380.37(a) | Records of training including the training source, content, dates, length of training and copies of certificates shall be kept. Staff #1 had documentation of the current CPR certification completed on 7/12/23, however the licensing rep requested 2 years of CPR certification to be able to measure compliance. The staff did not have documentation of the previous CPR certification. This staff has been employed since 3/7/2011. Staff would require CPR annually unless the training source provided a 2 year recertification. There was not a training document available to measure compliance of this 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. | The Program Assistant will complete audits of the staff's file to make sure that the time frames of all training is adhered to |
12/12/2024
| Implemented |
| 2380.39(c)(5) | Staff should have annual training in the safe and appropriate use of behavioral Supports, there was no documentation to reflect that staff #2 had this annual training. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Staff #2 had the annual behavior training as completed in Relias. The facility has a copy of the training that was completed |
12/11/2024
| Implemented |
| 2380.39(c)(6) | Staff should have annual training in the implementation of the individual plan. There was no documentation to reflect that staff #2 had this training. | 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 staff reviews each client's ISP prior to working with them. Staff #2 missed an ISP prior to working with the individual. The Area Manager and Program Specialist will inservice all staff on each ISP and IDT prior to them working with them |
12/12/2024
| Implemented |
| 2380.181(f) | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan mtg. Individual's 2, 3, 4, 5, 6, and 8 were missing this documentation in their file at the time of inspection. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The Program Director reviewed this regulation with each Program Specialist and documentation was provided accordingly. |
12/12/2024
| Implemented |
| 2380.186 | At the time of the inspection, it was stated that sharps should be locked and non-accessible to individuals. Throughout the inspection there was several pairs of scissors found in various program rooms that were not locked. | The facility shall implement the individual plan, including revisions. | The Program Director developed a plan for locking all sharps in the program areas and kitchens. The plan will be reviewed with all staff working in the ADS, |
12/13/2024
| Implemented |