Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257364 Renewal 12/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)Individual #1's annual physical examination completed on 5/09/2024 did not contain an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.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.On 12/30/2024, correspondence was sent to the residential provider to request that the PCP completes the missing sections of the annual physical form, with a return due date of January 13, 2025.  Upon receipt of the completed physical, the Director of SPARC and the assigned Program Specialist will review the form to ensure all fields are completed and are consistent with the ISP. 01/13/2025 Implemented
2380.111(c)(9)Individual #1's annual physical examination completed on 5/09/2024 did not fully document the individual's allergies. The physical examination form stated that the individual was allergic to penicillin only. The Individual Support Plan and other documentation from the primary care physician state that the individual is also allergic to blue dye, chocolate, Depakote and dairy.The physical examination shall include: Allergies or contraindicated medication.On 12/30/2024, correspondence was sent to the residential provider to request that the PCP completes the missing sections of the annual physical form, with a return due date of January 13, 2025. Upon receipt of the completed physical, the Director of SPARC and the assigned Program Specialist will review the form to ensure all fields are completed and are consistent with the ISP. 01/13/2025 Implemented
2380.111(c)(10)Individual #1's annual physical examination completed on 5/09/2024 did not document medical information pertinent to diagnosis and treatment in case of emergency. The section on the physical examination form to record that information was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.On 12/30/2024, correspondence was sent to the residential provider to request that the PCP completes the missing sections of the annual physical form, with a return due date of January 13, 2025. Upon receipt of the completed physical, the Director of SPARC and the assigned Program Specialist will review the form to ensure all fields are completed and are consistent with the ISP. 01/13/2025 Implemented
SIN-00234411 Renewal 11/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individuals shall be instructed upon initial admission and reinstructed annually in general fire safety, 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 first day of program was on 1/30/23 and she was not trained on fire safety until 2/1/23.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.On 2/1/23, the wavier participant received the regulatory required fire safety training, which was her second day back after returning to in-person supports (she had been receiving Teleservices during the COVID-19 Pandemic). Upon discovering this delay in training, the Senior Director of Programs audited all facility-based waiver participant files on 12/7/23, ensuring that all individuals received this very important training. The provision of this training on the first day of service, and annually safeguards all participants and staff, so all involved parties know how to prevent and respond safely to a fire emergency. 01/01/2024 Implemented
2380.21(u)The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. Individual #1 had her rights reviewed and signed on 2/28/22 and not again until 3/20/23. This exceeds the annual time frame required. Individual #2 date of admission was 1/30/23 and the rights were not reviewed and signed with individual until 4/25/23. The rights should have been read at the time of admission.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.Ensuring that all individuals are informed of their rights and how to report violations of such, is vital for all participants and guardians to know how to safeguard themselves and how to take action when their choices, needs, wants, abilities, and preferences are not respected, embraced, promoted and honored. By providing this information upon admission and annually, it ensures that all individuals have access to and understand how to protect their rights during the provision of SPARC services. Upon discovery of these lapses in time to comply with 2380.21(u), the Senior Director of Programs audited all SPARC waiver participant files on 12/6/23 and confirmed all individuals and guardians have been informed of Individual Rights within the last 365 days. 01/01/2024 Implemented
SIN-00214395 Renewal 11/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(g)Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. The 10/6/22 fire drill record documented "No" as the response for did all the individuals meet at the designated fire safe area (picnic table area).Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.During the drill on 10/6/22, the fire drill record contained a data entry error, as all individuals who participated in the drill did meet at the designated fire safe area. The fire drill record was corrected to accurately describe what occurred during the 10/6/22 unannounced fire drill. 12/05/2022 Implemented
2380.36(b)Staff #1 was last trained in fire safety on 10/25/21. Staff #1 did not receive annual training in fire safety for 2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff #1 has been away from the facility on an extended medical leave. Staff #1 will be trained in fire safety upon her return to the facility at the next scheduled program in-service on 12/16//2022. Documentation of completed training will be forwarded following training. 12/16/2022 Implemented
SIN-00195671 Renewal 11/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisonous substances were not locked and available. Lysol disinfectant spray was found in an unlocked drawer in a file cabinet in Program Room 5. The file cabinet was locked at the time of the inspection, but the top drawer where the disinfectant spray was found, opened when pulled by the inspector.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The poisonous substance was moved to a locked drawer immediately upon discovery. 12/17/2021 Implemented
2380.53(b)Poisonous substances must be kept in their original labeled container. An unidentified liquid was found in an unlabeled spray bottle in a utility closet. Three unlabeled spray bottles with different colored liquids were found in the laundry room. An unlabeled soap dispenser was found at the janitor's sink in the laundry room.Poisonous materials shall be stored in their original, labeled containers.Unlabeled poisonous substances have been and will continue to be discarded appropriately. The regulation was reviewed with the cleaning service on 12/7/2021. 12/07/2021 Implemented
2380.21(u)Individual #1 was informed of her rights on 6/29/2021 and Individual #2 was informed of his rights on 9/22/2021. Individual Rights have not been fully updated to reflect the new regulations. The missing rights include the right to: make choices and accept risks; refuse to participate in activities/services; privacy of person and possessions; and access to and security of individual possessions.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.All program participant rights have been updated to include revised regulations and signed. Please see Individuals #1 and #2 attached. 12/15/2021 Implemented
SIN-00160701 Renewal 08/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(c)In Room 12, there was a locked cabinet that contained 4 containers of powdered coffee creamer on 1 shelf. On the shelf underneath was 2 bottles of disinfectant cleaner and 2 cans of Lysol disinfectant spray, which stated "Seek medical assistance if ingested."Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.All program staff will be retrained on this regulation item by 9/6/2019. The provider will continue to self-monitor compliance with this regulation. ((All poisonous items will be removed immediately from areas where food is stored -CH 9/19/19)) 09/06/2019 Implemented
2380.111(c)(10)This section was blank on Individual #3's physical exam dated 2/5/2019.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The provider has requested an updated physical exam for Individual #1 from the residential provider. In addition, the cover letter accompanying requests for individual physical exams is updated to indicate that blank spaces are not acceptable and will be returned. 09/06/2019 Implemented
2380.173(1)(ii)Identifying marks were not listed in Individual #3's record.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The face sheet for Individual #1 is updated regarding identifying marks. The provider is reviewing all individuals¿ face sheets and updating them as needed. All individual face sheets will be reviewed and updated by 9/6/2019. 09/06/2019 Implemented
2380.181(e)(12)There were no recommendations on Individual #1's assessment dated 12/28/2018 and Individual #2's assessment dated 10/12/2018.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The provider has amended the annual program assessments of Individual #1 (12/28/2018) and PP (10/12/2018) with recommendations for specific programming and training per the regulation. The amended program assessments have been distributed to the individuals¿ teams. In addition, the Program Specialists have been coached on the expectations of the regulation item. 08/28/2019 Implemented
SIN-00138189 Renewal 09/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2's annual physical was late. One was completed 12-27-16, then not again until 01-17-18.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individuals who receive services will have physical examinations completed within the required time frame. The administrative assistant to the program will be responsible for tracking and communicating when individuals¿ physical examinations are due. Specifically, individuals ¿ or families/support staff on their behalf ¿ will receive a letter and/or email communication indicating that their physical exam is required in 60 days and again in 30 days from the due date. The SPARC Director will be copied on all communications in order to facilitate and evaluate the process. 10/01/2018 Implemented
2380.113(a)Staff #1's physical was late. She had one on 12-18-15, then not again until 03-17-18.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.Direct support professionals will have physical examinations completed within the required time frame. The administrative assistant to the program will be responsible for tracking and communicating when staff physical examinations are due. Specifically, direct support staff will receive a letter and/or email communication indicating that their physical exam is required in 60 days and again in 30 days from the due date. The SPARC Director will be copied on all communications in order to facilitate and evaluate the process. 10/01/2018 Implemented
2380.181(d)None of the eight assessments reviewed were signed or dated by the program specialist.The program specialist shall sign and date the assessment.The annual program assessment is completed in a web-based record keeping, data management software program. The provider will amend the annual program assessment template to include a signature line and date at the top of the current form with other identifying information. The SPARC Director is responsible for the review of accurate completion of program assessments. 11/30/2018 Implemented
2380.181(e)(13)(i)The information pertaining to the Individual #1's health was not updated in her current assessment. The assessment was completed in 2018 and the most recent medical information mention "upcoming appointments" in October of 2017.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.Individual #1¿s program assessment was updated accordingly and redistributed to the team on 10/4/18. The annual program assessment is completed in a web-based record keeping, data management software program. The provider will amend the annual program assessment template to include sub headings of 2380.181(e)(13) that are more consistent with regulation (e.g., health, motor/communication skills, etc.). Specifically, guidance will be placed in the form at this section that comments must address the individual¿s current level and progress over the past 365 days. The SPARC Director is responsible for the review of accurate completion of program assessments. The amendment is expected to be completed by 11/30/18. 10/04/2018 Implemented
SIN-00119835 Renewal 09/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had physical exam on 2/8/2016. She did not have another physical exam until 3/10/2017, which exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.All individuals will have a physical examination within the annual requirement. Residential providers are responsible for medical appointments and the program issues requests for physicals well in advance of due dates. A tracking system of at least 60 days in advance of due dates is currently in effect. The Program Specialists will continue to practice timely communication with other provider agencies and SCOs. 10/02/2017 Implemented
2380.181(a)Individual #6 had an assessment done on 11/25/2015. He did not have another assessment until 12/15/2016, which 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.All individual assessments will be completed within the annual requirement. A tracking system of at least 60 days in advance of assessment due dates is currently in effect. In the future, if an ISP needs to be rescheduled, the original date will be held with the individual, Program Specialist and SC and an additional meeting called for other team members at their convenience. The program will continue to practice timely communication with other provider agencies, families and SCOs. 10/02/2017 Implemented
2380.181(f) Individual #1's ISP meeting was held on 3/6/2017. Her assessment was provided to her team on 3/6/2017. Individual #2's ISP meeting was held on 4/12/2017. His assessment was provided to his team on 4/12/2017. Individual #3's ISP meeting was held on 12/5/2016. His assessment was provided to his team on 12/5/2016. Individual #4's ISP meeting was held on 12/7/2016. Her assessment was provided to her team on 12/7/2016. Individual #5's ISP meeting was held on 12/7/2016. Her assessment was provided to her team on 12/7/2016. Individual #6's ISP meeting was held on 12/29/2016. His assessment was provided to his team on 12/29/2016. Individual #7's ISP meeting was held on 8/2/2017. Her assessment was provided to her team on 8/2/2017. The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).All individual assessments will be provided to the plan lead within the 30-day requirement. In the future, cover letters from the Program Specialists accompanying individual assessments will be dated and emailed securely to SCs at least 30 days in advance of the ISP meeting date. 10/02/2017 Implemented
SIN-00097253 Renewal 08/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Direct service worker/staff 1 was hired on 2/9/2016 without a PA criminal history record check being requested by the agency. An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.All prospective employees will have a PA criminal history record check submitted prior to hire regardless of their state of residence. The Human Resource department will utilize a new hire orientation checklist in order to insure that all background checks are completed prior to employment. (PA Criminal History Check was completed on 8/11/16 with a result of No Criminal History)- CH 11/17/16 10/03/2016 Implemented
2380.91(a) Individuals 5 and 6 were not instructed on fire safety upon their initial admission. Individual 5 was admitted to the program on 10/5/2015 with fire safety being completed on 10/6/2015. Individual 6 was admitted to the program on 8/24/2015 with fire safety being completed on 10/6/2015.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.All individuals will be instructed in fire safety on their first day in the program. The Program Specialists will insure compliance with this regulation by completing a participant orientation on the individual¿s first day in the program, which includes fire safety training and is in the individual¿s orientation packet. Fire safety instruction is conducted annually and fire emergency evacuation on a monthly basis. 10/03/2016 Implemented
2380.111(c)(10)Two individuals' physical exams do not include medical information pertinent to diagnosis and treatment in case of an emergency. This area was left blank on individual 4's physical dated 5/9/2016. Also, on individual 5's physical dated 1/21/2016, the doctor left this area blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Moving forward, a letter will be attached to all physical examination forms explaining to physicians that all spaces on the physical form must be completed and that blank spaces will not be accepted. The paragraph on the letter explaining this is printed in bold face type. In addition, a similar statement has been printed on the physical examination form. The Program Specialists will review all physical examination forms submitted in order to insure completeness. Physical examination forms with blank spaces will be returned to physicians to complete. (The required information was added to the physical examination forms by the PCP on 11/22/16) - CH 11/22/2016 10/03/2016 Implemented
2380.173(1)(v)Individual 1 has an undated photo in his record. Individual 1 was admitted to the program on 5/9/2011. Each individual¿s record must include the following information: Personal information including: A current, dated photograph.All individuals¿ photographs were retaken and dated following the on-site inspection. Moving forward, all individuals¿ photographs will be retaken and dated on an annual basis in January beginning in 2017 or when they are admitted to the program. (updated photo was placed in Individual #1's record on 8/10/16) - CH 11/17/16 10/03/2016 Implemented
2380.186(c)(2)Not all areas of the ISP, pertaining to the 2380 program are being covered within the agency's ISP reviews. The ISPs for individuals 1, 2, 3, 4, and 6 all contain information regarding the outcomes established and progress on the outcomes and community activities attended. However, the ISP reviews do not contain information regarding behavioral and medical issues, or safety areas that affect the services provided to the individuals at the program. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The daily progress notes, monthly and quarterly reports have been revised to reflect each section of the ISP specific to the facility. The corrected ISP reviews have been implemented in the agency¿s data management system from which they are generated. The daily progress reports are currently being generated with the corrected ISP reviews and will subsequently populate the monthly reports in November 2016 and the quarterly reviews in January 2017. 10/03/2016 Implemented
SIN-00081804 Renewal 08/12/2015 Compliant - Finalized
SIN-00063208 Renewal 06/10/2014 Compliant - Finalized
SIN-00048445 Renewal 05/21/2013 Compliant - Finalized