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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(b) | On 4/7/26, at 12:25 PM, there was a translucent soapy liquid in an unlabeled, clear 12-ounce spray bottle located in a locked cabinet within the changing room of the Adult Development Training Program Area. | Poisonous materials shall be stored in their original, labeled containers. | Checked the locked cabinets to ensure that all chemicals were being stored in their original, labeled containers. |
05/15/2026
| Implemented |
| 2380.111(c)(3) | Individual #2 had physical examinations completed on 8/30/2024, and then again on 8/24/2025. Both physical examinations provided did not address a tetanus and diphtheria immunization. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | WFS 2380 program is going to submit a regulatory waiver application, due to clients diagnoses of epilepsy. The doctor has indicated an intolerance to tetanus, Diphtheria, and Pertussis vaccine. Patient is intolerant to T-DAP secondary to their active seizure disorder. Patient is restricted from receiving T-Dap, as per MD PC. PA LIC# MD 036284E |
06/30/2026
| Implemented |
| 2380.111(c)(4) | Individual #1's physical examination, dated 12/15/2025, did not include a vision or hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | The request was submitted to the family to have the doctor complete the hearing and vision screening. |
05/15/2026
| Implemented |
| 2380.111(c)(7) | Individual #1's physical examination, completed 12/15/2025, did not address health maintenance
needs. Individual #3's initial and current physical examination, completed on 7/14/25, did not include
an assessment of the individual's health maintenance needs, medication regimen, and the need
for bloodwork at recommended intervals. The corresponding field, entitled, "Recommended
further medical tests or examinations on the following: Bloodwork; Vision; Medical; HGB;
Hearing; Blood Pressure; Growth; Urinalysis," was left blank. Individual #5's current physical examination, completed on 3/9/26, did not address medical information pertinent to diagnosis and treatment in case of an emergency, as the corresponding field, entitled, "Emergency Medical Information," was left blank. | 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. | All missing information was resubmitted to be properly obtained. |
05/15/2026
| Implemented |
| 2380.113(a) | Direct Services Worker (DSW) #2 had a physical examination on 3/9/2023 and then again on 4/9/2025. This exceeds the every 2-year requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Individualized supervision was completed with the staff member. And the staff was trained on the regulation regarding the timeliness of their physical examination. |
05/15/2026
| Implemented |
| 2380.181(e)(6) | Individual #3's initial and current assessment, completed on 10/21/25, did not address their ability to safely use or avoid poisonous materials when in the presence of such materials, as the document contained contradictory information in the following manner: Under the criterion entitled, "Recognizes and avoids dangerous situations in the environment (e.g. fire, heat sources,
machinery, electrical outlets, poisonous materials, etc.)," "No" was indicated. However, in a subsequent criterion entitled, "Recognizes and safely uses or avoids poisonous materials," "Yes," was indicated.
Individual #4's current assessment, completed on 10/21/25, did not address their ability to safely use or avoid poisonous materials when in the presence of such materials, as the document contained contradictory information in the following manner: Under the criterion entitled, "Recognizes and avoids dangerous situations in the environment (e.g. fire, heat sources, machinery, electrical outlets, poisonous materials, etc.)," "No" was indicated. However, in a subsequent criterion entitled, "Recognizes and safely uses or avoids poisonous materials," "Yes," was indicated. | 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. | The assessments that contained contradictory information were checked and adjusted to reflect the accurate explanation of the questionable areas. |
05/15/2026
| Implemented |
| 2380.182(c) | Individual #3's Service Plan, last updated 1/27/26, contained the following discrepancies between their initial and current assessment, completed on 10/21/25, in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #3's Service Plan, last updated 1/27/26, stated, "[Individual #3] understands the dangers associated with heat sources." In contrast, Individual #3's assessment, completed on 10/21/25, informed that Individual #3 cannot recognize and avoid such dangerous heat sources. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The assessments that contained contradictory information were checked and adjusted to reflect the accurate explanation of the questionable areas. |
05/15/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(10) | Individual #1's physical examination completed 6/30/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination completed 7/8/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Wesley Family Services IDD policy #04.01 INDIVIDUAL HEALTH, states "the physical exam will be completed in its entirety, without blanks..... Site supervisors/Program Specialists will review the document to ensure accuracy."
Additionally, a new Physical form was revised to ensure inclusion of Medical information pertinent to diagnosis and treatment in case of emergency. This was accidentally omitted. |
10/01/2021
| Implemented |
| 2380.181(a) | Individual #2 had an annual assessment completed 8/13/20 and then again 9/13/21. | 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. | Due to some changes in services during COVID, there was some confusion regarding the bulletin regarding new admission assessments and returning to program. We believed a person was considered a new admission if they returned after 7/1/21 and would follow the new admission assessment criteria. We now completely understand that they are not considered a new admission. |
10/01/2021
| Implemented |
| 2380.38(b)(2) | Direct Service Worker #1, date of hire 4/19/21 and first date working with Individuals 4/26/2021, was provided training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 5/18/21. Direct Service Worker #2, date of hire 5/10/21 and first day working with Individuals 5/25/21, was provided training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 6/8/21. | 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. | A revised training plan was developed and implemented immediately indicating the first day trainings, prior to working with individual trainings, must complete within 30 days, etc. |
10/01/2021
| Implemented |
| 2380.38(b)(3) | Direct Service Worker #1, date of hire 4/19/21 first started worked with Individuals 4/26/2021, was provided training on Individual Rights on 5/5/21. | The orientation must encompass the following areas: Individual rights. | A revised training plan was developed and implemented immediately indicating the first day trainings, prior to working with individual trainings, must complete within 30 days, etc. |
10/01/2021
| Implemented |
| 2380.38(b)(4) | Direct Service Worker #1, date of hire 4/19/21 first started working with Individuals 4/26/2021, was provided training on recognizing and reporting incidents 5/3/21. | The orientation must encompass the following areas: Recognizing and reporting incident. | A revised training plan was developed and implemented immediately indicating the first day trainings, prior to working with individual trainings, must complete within 30 days, etc. |
10/01/2021
| Implemented |
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