Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00276971 Renewal 10/20/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(b)Staff #1 was hired on 8/17/25. There was no documentation to prove that Staff #1 has been a resident of Pennsylvania for the past two years. There was not a Federal Bureau of Investigation criminal history record check completed.If a prospective employe 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.As of October 1, 2025, the Director of Human Resources has implemented a policy that states PA Child Abuse, Pa State Criminal, and FBI Criminal checks are completed for all employees upon hire and on-going as required by regulation, and law. 11/19/2025 Implemented
2380.21(l)ODP Announcement 24-061 outlines the Federal requirements for individuals to be involved in decision-making about desired community activities, the regulatory requirements in Chapters 2380, 2390 and 6100, and what is required to comply with the regulatory requirements. Providers who deliver Community Participation Support and/or Day Habilitation in Chapter 2380 or Chapter 2390 programs must document conversations with individuals, beginning July 1, 2024, relating to their preferred community participation and activities at least quarterly. There was no documentation in Individual #1 and Individual #2's and Individual #4's records that these conversations took place. There were 1/4ly conversations documented, however they were a review of activities that Individual #1, Individual #2 and Individual #4 participated in over the previous quarter. Individual #3's record included two conversations that contained the required information.An individual has the right to make choices and accept risks.Upon identification of this deficiency, the program's assistant coordinator created a CPS conversation form that shall be utilized during each quarterly meeting had with each program participant. Document includes narrative of conversation that occurred, risk factors, individual needs to safely participate in desired outings, and individual preference. 10/21/2025 Implemented
SIN-00231637 Renewal 11/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Every program room had a cabinet which stored their poisons. Several of their cabinets used what appeared to be a child lock to keep the poisons secure. However, this type of lock was able to be opened by just pinching the sides of the lock to open the device and have full access to the poisons. This lock did not secure the poisons as the regulation requires. The poisons were easily accessible with the lock that was being utilized.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Child safety locks removed and replaced with pad locks. 11/28/2023 Implemented
2380.91(a)Individual #2 did not have proper documentation of the annual fire safety training. There was a fire safety form which was signed and dated 8/4/23 by the individual. However, the form was not properly filled out. The areas of the training were not filled in on this form and it is unable to determine if the topics were covered with this individual.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 #2 fire safety form was completed on 11/16/23. 11/16/2023 Implemented
2380.111(a)Individual #1 had a physical on 9/19/22 and then not again until 10/6/23. This exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #1 completed his physical on 11/17/23. 11/17/2023 Implemented
2380.111(c)(5)Individual #1 did not have TB testing with negative results on his physical exam. Staff report that he has reactions to the TB tests. A recommendation to have the QuantiFERON test completed to meet the requirement of this regulation was made.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Individual #1 had the Quantiferon TB blood test completed on 11/29/23 with a negative result. 11/29/2023 Implemented
SIN-00212773 Renewal 11/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(b)Staff #1 had a physical exam, however the physician did not date the exam.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.The company that we formally used for our staff physicals is no longer available to have Staff # 1's physical corrected so instead we had staff # 1 go for another physical at our new provider. This was completed on 11/30/22. 11/30/2022 Implemented
SIN-00068192 Renewal 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(d)The First Aid Kit contained a Band-Aid Antiseptic that was expired as of 2/2014. First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.New Antiseptic was place in the First Aid Kit. Checking expiration dates was added to the program's monthly physical site monitoring tool that is used by Supervisors, each month. 10/30/2014 Implemented
SIN-00255212 Renewal 11/06/2024 Compliant - Finalized
SIN-00165446 Renewal 11/18/2019 Compliant - Finalized
SIN-00147034 Renewal 12/05/2018 Compliant - Finalized
SIN-00125307 Renewal 12/21/2017 Compliant - Finalized
SIN-00104414 Renewal 01/12/2017 Compliant - Finalized
SIN-00085889 Renewal 01/21/2016 Compliant - Finalized
SIN-00053848 Renewal 09/30/2013 Compliant - Finalized