Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230408 Renewal 09/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(b)Facilities shall have an annual onsite fire safety inspection by the local fire department. The agency had an annual fire safety inspection on 9/1/22 and there is no record or documentation that one has occurred since.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.Facility will have an annual Fire Safety Inspection by the local fire department. The next Fire Safety Inspection is scheduled for October 5, 2023. If the next inspection is not within 1 calendar year, VP of IDD will inform in writing to the local fire department the address of the facility and the number and disabilities of the clients served within the past year. 09/28/2023 Implemented
2390.151(e)(10)Individual #1's assessment dated 2/10/23, Individual #2's assessment dated 12/9/22, and Individual #3's assessment dated 4/18/23 did not include lifetime medical histories.The assessment must include the following information: A lifetime medical history.Assessment was revised to include Lifetime Medical History information. See attachment. 10/31/2023 Implemented
SIN-00211119 Renewal 09/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)The Client Rights statement reviewed with and signed by Individual 1 on 7/29/2022 were not complete. The Client Rights statement did not include the following rights: 21(d) A court's written order that restricts a client's rights shall be followed; 21(e) A court-appointed legal guardian may exercise rights and make decisions on behalf of a client in accordance with the conditions of guardianship as specified in the court order; and 21(r) A client's rights shall be exercised so that another client's rights are not violated.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Individual Rights Policy is revised to include the following rights: 21(d) A court's written order that restricts a client's rights shall be followed; 21(e) A court-appointed legal guardian may exercise rights and make decisions on behalf of a client in accordance with the conditions of guardianship as specified in the court order; and 21(r) A client's rights shall be exercised so that another client's rights are not violated. See attachment 1. 11/11/2022 Implemented
2390.49(a)(1)Staff 1 did not complete 24 hours of training in training year 7/01/2021 to 6/30/2022.The following shall complete 24 hours of training related to job skills and knowledge each year: Directive supervisors of floor supervisors.Orientation and Annual Training Plan is developed to assure that every DSP and SSP staff is receiving the required training at orientation and annually. See attachment # 2. 10/31/2022 Implemented
2390.49(b)(1)Per staff training records for Management Staff 2, the staff completed only 8.25 hours of training during the provider's 07/01/2021 to 06/30/2022 training year. Management staff must complete 12 hours of training annually.The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.Orientation and Annual Training Plan is developed to assure that every DSP and SSP staff is receiving the required training at orientation and annually. See attachment #3. 10/31/2022 Implemented
2390.49(c)(2)There is no evidence in the staff record to support that Management Staff 2 received training on the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the Child Protective Services Law, the Adult Protective Services Act, and applicable protective services regulations during the provider's 07/01/2021 to 06/30/2022 training year.The annual training hours specified in subsections (a) and (b) 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.Orientation and Annual Training Plan is developed to assure that every DSP and SSP staff is receiving the required training at orientation and annually. See attachment # 2. On 9/30/2022 , Mgmt Staff 2 completed Abuse and Neglect of Individuals with I/DD & Abuse, Neglect, and Exploitation of Older Adults. See attachment # 4 10/31/2022 Implemented
2390.49(c)(3)Staff 1 did not complete the following required training during training year 7/01/2021 to 6/30/2021: Client Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Orientation and Annual Training Plan is developed to assure that every DSP and SSP staff is receiving the required training at orientation and annually. See attached Outline. Staff 1 has since completed training on Client Rights. See attachment # 5. 05/31/2022 Implemented
2390.49(c)(4)Staff 1 did not complete the following required training during training year 7/01/2021 to 6/30/2021: Recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Orientation and Annual Training Plan is developed to assure that every DSP and SSP staff is receiving the required training at orientation and annually. See attachment #2. Staff 1 has since completed training on Recognizing and Reporting Incidents. See attachment # 6 10/31/2022 Implemented
SIN-00194698 Renewal 09/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.48(b)(1)Staff #1 was hired on 11/9/20, Staff #2 was hired on 7/13/20, and Staff #3 was hired on 1/6/20, and their orientations did not include the application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.Staff Persons #1, #2, & #3 will receive the recommended trainings by 10/13/2021. 11/05/2021 Implemented
2390.49(c)(1)Staff #4 did not receive annual training on the application of person-centered practices, including community integration, client choice and supporting clients to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.Staff Person #4 will receive recommended training by 10/13/2021. Training Documentation will be forwarded. 11/05/2021 Implemented
2390.49(c)(2)Staff #4 did not receive annual training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse.The annual training hours specified in subsections (a) and (b) 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.Staff Person #4 will receive recommended training by 10/13/2021. Training Documentation will be forwarded. 11/05/2021 Implemented
2390.49(c)(3)Staff #4 did not receive annual training on client rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Staff Person #4 will receive recommended training by 10/13/2021. Training Documentation will be forwarded. 11/05/2021 Implemented
2390.49(c)(4)Staff #4 did not receive annual training on recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff Person #4 will receive recommended training by 10/13/2021. Training Documentation will be forwarded. 11/05/2021 Implemented
2390.49(c)(5)Staff #4 did not receive annual training on the safe and appropriate use of behavior supports.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 a client.Staff Person #4 will receive recommended training by 10/13/2021. Training Documentation will be forwarded. 11/05/2021 Implemented
2390.49(c)(6)Staff #4 did not receive annual training on the implementation of the individual plan.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 a client.Staff Person #4 will receive recommended training by 10/13/2021. Training Documentation will be forwarded. 11/05/2021 Implemented
SIN-00251492 Renewal 09/25/2024 Compliant - Finalized