Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279257 Renewal 12/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)The physical that was completed on 3/19/25 prior to Individual #1's 4/11/25 admission to the program does not include vision and hearing screenings, nor does it include recommendations by the physician for vision and hearing screenings. The boxes and lines for those items on the physical form were left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Going forward, provider/nurse manager will provide the individual/parent/guardian with a letter, attached to the PA annual physical exam form #. The letter directs attention to items that are often incomplete on the form: hearing and vision screening, diet, information pertinent to diagnoses and treatment in case of emergency, and Eligibility for ICFC/ID Care. (see copy of letter) 12/31/2025 Implemented
2380.113(c)(3)The following employee physicals do not include a statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2: Staff #1-employee physical dated 3/20/25.The page related to that information for the physical form was left blank. Staff #2-employee physical dated 11/29/24. Agency employee physical form was not used for the physical. There was no statement included.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.A separate paper with a signed statement that the person is free of serious communicable diseases has been added to each employee health form. A database is maintained by the CEO/nurse manager to ensure that each employee obtains a physical exam every two years. (see copy of statement) 12/31/2025 Implemented
2380.113(c)(4)The employee physical for staff #2, completed on 11/19/24, does not include Information of medical problems which might interfere with the safety or health of the individualsThe physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.A standard form was not provided to this employee, which includes health information that might interfere with safety or health of the individuals. A standard form will be provided to each employee upon hire and every two years, which includes this information. Nurse manager/CEO maintain database of employee physicals. 12/31/2025 Implemented
2380.21(l)A quarterly report was completed for individual #1 on 9/26/25. The report covered the review period for 6/27/25 through 9/26/25. The report states that a discussion was held between Individual #1 and the program specialist regarding CPS services and the individual's choices for community integration. However, it does not specify the date of the conversation, nor does it document the summary of the discussed content of the conversation with individual's preferences as per requirements of ODP Announcement 24-061.An individual has the right to make choices and accept risks.A new Quarter Progress Note has been designed and implemented, which is similar to the AAW QPN (found on ODP website). The form includes date of conversation and summary of discussed content about the individual's preferences during CPS. The form has been imlemented immediately, starting 12/31/25. (see new form) 12/31/2025 Implemented
2380.181(f)The annual assessment completed on 6/7/25 for Individual #2 was not provided to the team 30 days prior to the ISP date. The assessment was provided to the team on 6/30/25 and the ISP meeting was held on 7/7/25.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.In this instance/violation, the previously-employed program specialist was responsble for completing the assesment and submitted it to the ISP team in a timely manner, 30 days prior to the individual plan meeting. The new program specialist noticed the error and provided the assessment, albeit late, to the team. CEO has reviewed all annual assessments with PS. 12/31/2025 Implemented
SIN-00261008 Renewal 02/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(b)Staff #1 had a Pennsylvania State background check prior to employment with the agency, however they did not have a signed statement declaring that they had been a resident of PA for 2 years prior, therefore an FBI background check would need to be conducted.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.We reviewed all employee records and did, indeed, locate Staff #1's application for employment. On that application, she attested that she had been a resident of Pennsylvania for two years prior to hire. In the future, we will review all employee files more closely prior to inspection to assure that all employee's documents are in the correct file. As a side, the application is included in an employee pre-employment packet; each applicant completes that packet prior to hire. Please see supporting document: Staff #1's job application from 2024. 03/10/2025 Implemented
2380.91(a)Individual #1 did not have Initial Fire Safety Training upon admission, instead fire safety training took place in Feb when the annual training was done with the other individualsAn 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.Program Specialist has now included the agency's fire safety training in our admission packet and PS will maintain these packets to ensure that each program applicant completes fire safety at ADMISSION to program. The packet was prepared on 3/7/25 with the fire safety training placed in the admission materials/packet. ( see supporting documentation submitted) 03/10/2025 Implemented
2380.21(u)The individual Rights statement for individual #1 was signed on 1/8/25, however their date of admission was on 10/4/24. Rights need to be signed upon 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.The Program has now included Individual Rights form in agency's admission packet, along with all other admission forms. This was completed March 7, 2025. 03/10/2025 Implemented
SIN-00239511 Renewal 02/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(b)There is no attestation of residency stating whether or not new staff #1 or new staff #2 has lived within this Commonwealth for the 2 years prior to the date of hire to indicate whether or not an FBI check would need to be 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.A revised employee application has been created to include an attestation of residency within the Commonwealth for two years prior (attachment #1); CEO (who is hiring manager) will use this attestation to determine whether FBI (non-resident of PA in past two years) or PA State Police checks will be performed. 03/01/2024 Implemented
2380.89(e)Alternate exit routes were not documented on fire drills. The same exit was used for evacuation for all drills throughout the year. Plan of correction was initiated on the date of inspection by conducting a fire evacuation drill using an alternate route when the fire alarm was tested.Alternate exit routes shall be used during fire drills.Plan of correction began on the actual day of inspection, 2/1/24, while investigators were present at facility. An unannounced fire drill was performed, all staff and participants were directed to the side door/alternate exit and safely exited to proceed to the prescribed meet up space outdoors. All staff and participants received education on this topic and report understanding of the rule. Alternate exit will be used for at least 4 drills throughout each year. 02/01/2024 Implemented
2380.181(a)Individual #1's most recent assessment was completed on 2/19/23. The previous assessment was completed on 2/1/22. There were 384 days between assessments, exceeding the annual (365-day) requirement by 19 days.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.CEO has met with Program Specialist (PS) on two occasions since the inspection on 2/1/24 and have reviewed all participant files to check for this violation: no other violations were noted; all assessments were completed within 364 days. 03/04/2024 Implemented
2380.21(u)The review of individual rights was last completed with individual #1 on 1/17/23. There is no documentation of individual rights being reviewed in 2024 as of this inspection date, 2/1/24.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.Program Specialist (PS) reviewed individual rights with individual #1 on 2/16/24 and signed document has been filed. (Attachment #4). PS completed a file review of all participants and found two additional violations; each of these two participants met with PS by 2/16/24; documentation was placed in each file. CEO and PS have decided that documentation of review of individual rights will be completed for all participants by January 10 of each year. A column "review of individual rights" has been added to program specialist spreadsheet (attachment #3) to aid in compliance. 02/16/2024 Implemented
2380.181(f)There is no documentation in the record indicating that the program specialist provided the assessment for individual #2 to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Program Specialist (PS) emailed Individual #1's Supports Coordinator on 2/16/24, which is at least 30 days prior to individual plan meeting. (Attachment #7). PS reviewed all participant's files. Two additional violations were noted (assessments completed timely, but not submitted to SC in timely manner). PS emailed the the two participant's documents to their respective SCs by 2/28/24 and has placed documentation in each participant's file. 03/04/2024 Implemented
SIN-00219031 Renewal 01/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(c)Food items were stored in a locked closet along with cleaners.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.CEO will educate all staff that no foods are to be stored in any area that contains poisonous materials. All foods are to be removed immediately from locked storage cabinet containing cleaners and placed in the kitchen in cabinets. 02/20/2023 Implemented
2380.82A non-fire exit leading to the breezeway did not have a latch on the interior lock. Both sides of the lock were key enabled.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Lock was replaced on 2/16/2023 . Photo sent to licensing. 02/16/2023 Implemented
2380.89(a)A fire drill was not completed for November 2022.An unannounced fire drill shall be held at least once a month.We had realized that we had not performed the fire drill for November 2022 on December 7, 2022. We immediately conducted an unannounced fire drill that day, Dec. 7, 2022. 02/10/2023 Implemented
2380.91(a)There is no fire safety training for Individual #2 or Individual #3.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.Individuals #2 and #3 were instructed in English on February 1, 2023 about fire safety, were escorted through evacuation procedures on that day, instructed in fire drill responsibilities, shown in person the designated outside meeting safe place in the event of an actual fire (same area as fire drill safe space), and instructed in smoking safety procedures, which is at least 30 feet away from the building. A signed training record was emailed to Licensing. 02/01/2023 Implemented
2380.111(c)(10)Information pertinent to diagnosis and treatment in case of emergency is blank on the physicals for Individual #2 and Individual #3.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The RN/CEO will contact both individual #2 and #3 and guardians, ask them to contact physician/PCP and add medical information pertinent to diagnosis and treatment in case of emergency. 02/27/2023 Implemented
2380.39(c)(6)Verification that the annual plan implementation training was completed was not documented in the files for Staff #1 & Staff #2.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 an individual.Staff #1 and Staff #1 completed the Foundations of ISP Development ODP module. Photos of training evidence sent to Licensing. 02/27/2023 Implemented
2380.123(d)The medication Clonazepam 2mg tablet prescribed to Individual #1 was stored in an unlocked bag in the program space.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.CEO will purchase locked containers for all prescription medications and syringes. The Clonazepam 2 mg. was placed in a locked container. A photograph of this medication and locked container will be sent to Inspector. 02/17/2023 Implemented
SIN-00174013 Initial review 07/14/2020 Compliant - Finalized