Adelphoi Manor

Citation, complaint inspection : 55 Pa. Code § 3800.19 Consent To Treatment

In 1 of 1 child records reviewed, the record of Child A did not contain a consent to treatment. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, complaint inspection : 55 Pa. Code § 3800.243 Content of Records

In 1 of 1 child records reviewed, the record of Child A did not contain a social security number. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

In 5 of 10 child records reviewed, the following was found regarding safety plans: The records of Child B, C, D, H and I indicate that the child has a present history of a health or safety risk and a safety plan was not located in the record. The agency shall develop a plan to assure that this mandate is being met. The plan shall include the staff position responsible for monitoring and ensure regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.58.e Staff Training

In 1 of 18 tenured staff records reviewed, the record of Staff Member A contained training in first aid, Heimlich techniques and cardiopulmonary resuscitation on 01/05/2023, and an updated training was not completed until 01/10/2025. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

In 1 of 4 child records reviewed, the record of Child D contained a health and safety assessment that indicated a history of substance use, and a safety plan for this behavior was not located in the record. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, complaint inspection : 55 Pa. Code § 3800.205.b Staff Training

On 02/17/2025, Staff Member A utilized an untrained restrictive procedure technique on Child A. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, complaint inspection : 55 Pa. Code § 3800.32.b Specific Rights

Child A was found to be the subject of regulatory abuse by Staff Member A. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, complaint inspection : 55 Pa. Code § 3800.205 Staff Training

During a restrictive procedure on /2023, Staff Member A utilized an untrained technique on Child A. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.149.b Emergency Medical Plan

In 1 of 10 child records reviewed, the record of Child I did not include documentation that the emergency medical plan was provided to the child's parent, and if applicable, the child's guardian or custodian upon admission. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.243.1 Content of Records

In 1 of 10 child records reviewed, the record of Child G did not include a social security number. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.243.1 Content of Records

In 4 of 10 child records reviewed, the records of Child D, Child E, Child G, and Child I did not include documentation of religious affiliation. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.272 Admission to Secure Care

In 1 of 10 child records reviewed, the record of Child | did not include a court order. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.272 Admission to Secure Care

In 1 of 18 tenured personnel records reviewed, Staff Member A completed mandated reported training on 07/16/2018, and an updated training was not completed until 09/12/2023. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.132.d Fire Drills

The fire drill conducted in March 2024 did not include documentation of an evacuation time. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

In 2 of 4 child records reviewed, the following was found regarding health and safety plans: The record of Child C indicated that the child has a history of aggressive behavior. The safety plan located in the record dated 03/14/2024 did not include a plan to prevent the aggressive behaviors from occurring. The record of Child D indicated that the child has a history of aggressive behavior, and a safety plan was not located in the record. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.224 Development of the ISP

In 3 of 4 child records reviewed, the following was found regarding Individualized Service Plans: Child A was admitted on , and an Individualized Service Plan was not completed until 10/19/2024. Child B was admitted on , and an Individualized Service Plan was not completed until 04/15/2024. Child C was admitted on , and an Individualized Service Plan was not completed until 10/26/2023. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.243.1 Content of Records

In 1 of 4 child records reviewed, the record of Child A did not include religious affiliation. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, complaint inspection : 55 Pa. Code § 3800.82.a Poisions

or iii glass cleaner was left in a bathroom used by residents and was not properly locked after usage. The facility will need to provide a plan that will assure that all poisonous materials are locked and inaccessible to residents. This plan should indicate how the plan will be reinforced with staff members and the staff position that will implement and monitor the plan developed by the facility.

Citation, complaint inspection : 55 Pa. Code § 3800.142 Health and Safety Plan

Upon Child A's admission, a health and safety assessment was completed by Staff Member A. A written health and safety plan was necessary and was completed by Staff Member A. The details of this plan were not communicated adequately to all staff that were responsible for the care of the child. The facility is expected to develop a plan that will assure that all pertinent information is effectively communicated to all staff that will be responsible for the care of each child at the facility. The plan should include the staff position responsible for implementing and monitoring this plan.

Citation : 55 Pa. Code § 3800.143.a Child Health Examination

In 1 of 2 child records reviewed, Child #2 was admitted to the facility on|3/15/202 | and a physical examination was not completed within 15 days of admission. There was no documentation of efforts made to get the child the examination, and the reasons why the initial examination was not completed was not documented. This is not in conformity with the COVID-19 pandemic exceptions. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation : 55 Pa. Code § 3800.144.b Dental Care

In 1 of 2 child records reviewed, Child #2 was admitted to the facility off 3/15/2021] and a dental examination was not completed for the child. There was no documentation of efforts made to get the child the examination, and the reasons why the initial examination was not completed was not documented. This is not in conformity with the COVID-19 pandemic exceptions. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation : 55 Pa. Code § 3800.145.b Vision Care

In 1 of 2 child records reviewed, Child #2 was admitted to the facility or| 3/15/2021] and a vision screening was not completed for the child. There was no documentation of efforts made to get the child the screening, and the reasons why the initial screening was not completed was not documented. This is not in conformity with the COVID-19 pandemic exceptions. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance. 05/04/2021 www.dhs.pa.gov 3 0f 5

Citation : 55 Pa. Code § 3800.146.b Hearing Care

In 1 of 2 child records reviewed, Child #2 was admitted to the facility off 3/15/2021] and a hearing screening was not completed for the child. There was no documentation of efforts made to get the child the screening, and the reasons why the initial screening was not completed was not documented. This is not in conformity with the COVID-19 pandemic exceptions. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance. 05/04/2021 www.dhs.pa.gov 4of5

Citation, complaint inspection : 55 Pa. Code § 3800.32 Specific Rights

During an incident that occurred on 11/25/2020, Staff Member A punched Child #1 in the leg multiple times during a restraint. This is not compliant with Safe Crisis Management techniques. During an incident that occurred on 11/25/2020, Staff Member B punched Child #1 in the face multiple times. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.

Citation, renewal inspection : 55 Pa. Code § 3800.52 Staff Hiring, Retention and Utilization

In 1 of 11 newly hired personnel records reviewed, Staff Member A was hired on 8/12/2019 and did not receive a ChildLine clearance until 8/21/2019. A disclosure statement was signed and dated on 8/12/2019. A receipt of application for the clearance was dated 8/13/2019. The agency shall develop a plan to assure that this mandate is being met. The plan shall identify the staff position responsible for monitoring and ensuring regulatory compliance.