Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258946 Renewal 01/17/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(3)Staff # 1's physical examination dated 8/9/24, Staff #2's physical examination dated 8/14/23, staff #3's physical dated 8/26/24, and Staff #4's physical dated 12/6/23 did not include a signed statement that the person is free of serious communicable diseases.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.Serve has developed a physical form including the statement "At the time of this physical, is the employee free from communicable diseases? Yes or No" 02/13/2025 Implemented
2380.173(1)(ii)Individual #1's record did not include identifying marks as this section of her record was left blank.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.Peer review of client files to ensure all sections are complete as required by regulation. 01/20/2025 Implemented
2380.173(1)(v)The photo in Individual #3's record was not dated.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Peer review of client files to ensure all photos are dated. 01/20/2025 Implemented
2380.181(e)(10)Individual #1's assessment dated 12/19/24 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.Annual assessment and lifetime medical history will be combined into one document to ensure completion of the entirety. 02/13/2025 Implemented
2380.21(n)An individual has the right to privacy of person and possessions. The facility has multiple cameras inside the building/program areas where the individuals receive services. There was no record or documentation that individuals were made aware that they are being recorded on camera.An individual has the right to privacy of person and possessions.Serve Client Rights statement has been updated to include notice that individuals are being recorded on camera. 02/13/2025 Implemented
2380.21(u)Individual #4 was informed of their individual rights on 4/10/23 and then again in 4/12/24. This exceeds the requirement.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.Serve will completed Client Rights review twice per year. 02/10/2025 Implemented
2380.39(c)(4)Staff #5 did not have documentation or record of receiving annual training on recognizing and reporting incidents in the annual training year 1/1/24-12/31/24.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Required trainings will be assigned monthly. Staff failure to complete within the assigned month will result in disciplinary action up to and including termination. 01/20/2025 Implemented
2380.155(c)(2)Individual #2's Positive Behavior Support Plan/ Behavior Support plan, that did not include the date the plan was created did not include an assessment of the behavior, including the suspected reason for the behavior.The behavior support component of the individual plan shall include: An assessment of the behavior, including the suspected reason for the behavior.Positive Behavior Support Plans have been updated to include all numbered elements per Regulation 2380.155. 02/13/2025 Implemented
2380.155(c)(4)Individual #2's Positive Behavior Support Plan/ Behavior Support plan, that did not include the date the plan was created did not include a target date to achieve the outcome.The behavior support component of the individual plan shall include: A target date to achieve the outcome.Serve Positive Behavior Support Plans have been updated to include all numbered elements per Regulation 3280.155. 02/13/2025 Implemented
SIN-00259650 Unannounced Monitoring 01/02/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(13)(i)Individual #1's assessment dated 10/18/24 did not include their progress over the last 365 calendar days and current level in the area of health. This section of Individual #1's assessment only discussed their physical examination that occurred on 12/8/2021, and Individual #1 being prescribed medical marijuana on 4/5/22.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 #1s assessment has been corrected and updated. 03/03/2025 Implemented
2380.21(j)On 12/18/24, Individual #1 "slammed his head off a table" according to agency documentation from Individual #1's communication log by Staff #1. The communication log for Individual #1 on 12/18/24 documented "had a rough day lot of hard sibs (self-injurious behaviors) with the following possible marks: goose egg on the forehead from slamming his head off a table" documented by Staff #1. The agencies Community Participation and Supports Monthly Progress Note Behavior Frequency Data Collection dated Dec 18, 2024, for Individual #1 documented between 11:30-12:30 "head to table (hard) 1." During an interview conducted on 1/17/25 with Staff #1 they stated Individual #1 had a goose egg on the right side, and following Individual #1 hitting their head Staff #1 did check Individual #1 and utilized first aid training to Individual #1 including monitoring Individual #1. The agencies Enterprise Incident Management (EIM) report under the summary of Investigator's findings also documented that Individual #1 was checked and simple first aid was given. The agencies EIM also documented that Staff #1 observed Individual #1 had a goose egg on the right side of Individual #1's forehead that was a little swollen but had no bruising. The agency noted on documents that individual #1 "slammed their head hard" and "head to table (hard)". The agency neglected to have Individual #1 be evaluated to receive emergency medical treatment for their head injury on 12/18/24.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Serve, Inc. has updated "Medical Emergency Procedures" to include emergency room visit or call 911 for all head injuries. 02/11/2025 Implemented
2380.39(c)(6)The agency submitted an Individual Support Plan (ISP) Review Checklist training for Individual #1 on 1/7/25 that included 8 agency staff signatures on the document, and that document submitted for the ISP Review Checklist training form/document for Individual #1 did not include the signature of Staff #1. The licensing representative requested additional documentation on ISP training for Individual #1 for Staff #2 on 1/17/25. On 1/21/25, the agency submitted a 2nd Individual Support Plan (ISP) Review Checklist training for Individual #1 that was identical to the initial documented submitted on 1/7/25, however it now included Staff #1's signature with the date 1/16/24 making 9 agency staff signatures on the document. The 2nd Individual Support Plan (ISP) Review Checklist training for Individual #1 that was submitted that now included Staff #2's signature and the date 1/16/24, the form appears to be fraudulent with the document being signed by Staff #1 and back/predated over a year ago.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.All new staff will sign updated orientation document to indicate understanding that "ISPs must be reviewed prior to working with the individual. Staff will sign/date the ISP review checklist attached to the ISP plan and/or updates in the individual's book." 02/28/2025 Implemented
2380.155(c)(1)Individual #1 has a "Positive Behavior Support plan"/behavior support plan component to their individual plan updated specific for Serve on 12/19/24, and their positive behavior support plan does not include the specific behavior to be addressed.The behavior support component of the individual plan shall include: The specific behavior to be addressed.Serve, Inc. has updated the BSP form to include all components as required by relevant regulations. 02/10/2025 Implemented
2380.155(c)(2)Individual #1 has a "Positive Behavior Support plan"/behavior support plan component to their individual plan updated specific for Serve on 12/19/24, and their positive behavior support plan does not include an assessment of the behavior, including the suspected reason for the behavior.The behavior support component of the individual plan shall include: An assessment of the behavior, including the suspected reason for the behavior.Serve, Inc. has updated the BSP form to include all components as required by relevant regulation. 02/10/2025 Implemented
2380.155(c)(3)Individual #1 has a "Positive Behavior Support plan"/behavior support plan component to their individual plan updated specific for Serve on 12/19/24, and their positive behavior support plan does not include the outcome desired.The behavior support component of the individual plan shall include: The outcome desired.Serve, Inc. has updated the BSP form to include all components as required by relevant regulation. 02/10/2025 Implemented
2380.155(c)(4)Individual #1 has a "Positive Behavior Support plan"/behavior support plan component to their individual plan updated specific for Serve on 12/19/24, and their positive behavior support plan does not include a target date to achieve the outcome.The behavior support component of the individual plan shall include: A target date to achieve the outcome.Serve, Inc. has updated the BSP form to include all components as required by relevant regulation. 02/10/2025 Implemented
SIN-00235602 Renewal 01/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)The annual assessment for Individual #1 was not provided to the individual plan team members at least 30 calendar days prior to the individual plan meeting. The individual's current annual assessment was completed on 6/20/2023 and provided to the team members on 6/20/2023. The annual individual plan meeting was held on 7/12/2023.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Serve, Inc. will ensure the assessment is provided to Individual #1 plan team members at least 30 calendar days prior to the individual plan meeting with a tracking sheet showing the annual meeting dates and the required assessment date of 30 days prior to the meeting. The assessment date on the tracking sheet will actually be 60 days prior to the meeting date to allow ample time to complete prior to the 30-day requirement. 02/01/2024 Implemented
SIN-00216747 Renewal 01/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #1 was admitted into the provider's facility effective 06/13/2022. Per the Individual Record, the provider did not issue an initial individual assessment for Individual #1 until 09/01/2022, 81 calendar days after the individual's date of admission to the facility. This exceeds the regulatory timeframe by 21 calendar days, putting the assessment date outside of the allowable 15-day grace period for timing requirements under this Chapter.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.Serve, Inc's. Assessment has specified in it the 55PA Code Chapter 2380 regulations with the exception of 181(A). The assessment is compiled beginning with the admission date and is based on assessment instruments, interviews, progress notes, and observations. 181(A) - requirements for the Initial assessment and Annual thereafter assessment has been added to the beginning of the assessment. The due date will be calculated and coordinated by the Program Specialist on the date of admission to ensure that the Assessment is completed within 60 days. 02/13/2023 Implemented
SIN-00197746 Renewal 02/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)A document dated 1/20/21 from "Guthrie Employee Health" was submitted for review as the employee physical for Staff # 1. This document was not a physical exam and did not contain the required items as follows: The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant, a general physical exam, a signed statement that the person is free of serious communicable disease and information of medical problems which might interfere with the safety or health of the individuals. Documentation of a clear chest x-ray being completed in leu of Tuberculin skin testing due to past positive results was provided. X-ray was completed on 8/20/20.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.Staff #1 was immediately scheduled to have a physical completed by PhysicianCare P.C. Occupational Health Services. Staff # 1¿s physical was completed on 2/7/2022. This physical was completed, signed and dated by Jeffrey Ryck, CRNP. This physical included a signed statement that Staff #1 is free of communicable disease and a signed statement that Staff #1 is medically qualified without accommodations. 02/07/2022 Implemented
SIN-00162322 Renewal 09/12/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Both Individual #1 and Individual #2 had late annual fire training. Training was held on 04-19-18 and then not again until 05-18-19.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.The annual training was completed a month late. In order to ensure that this is completed annually per regulation, the responsibility has been assigned to the chair of the safety committee, Currently Nathan Rice, Internal Operations Manager. The fire safety training has been scheduled to occur on Friday, October 18, 2019. It has been rescheduled to coincide with National Fire Prevention month which occurs every October. If any staff or individuals are not in attendance on this day, the training will be completed for them by the end of October. 10/10/2019 Implemented
2380.181(e)(13)(i)Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of healthThe assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan. All assessments will include progress over the past year and current level of functioning in the area of Health. Current completed assessments will have this progress and from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019. All newly completed assessments will cover the progress and growth from the prior year. the Program Specialist will be responsible for ensuring this occurs. 11/30/2019 Implemented
2380.181(e)(13)(ii)Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of motor and communication skills.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan. All assessments will include progress and growth over the past year in the area of motor and communication skills. Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019. All newly completed assessments will cover the progress and growth from the prior year. the Program Specialist will be responsible for ensuring this occurs. 11/30/2019 Implemented
2380.181(e)(13)(iii)Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of personal adjustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan. All assessments will include progress and growth over the past year in the area of Personal Adjustment. Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019. All newly completed assessments will cover the progress and growth from the prior year. the Program Specialist will be responsible for ensuring this occurs. 11/30/2019 Implemented
2380.181(e)(13)(iv)Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of socializationThe assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan. All assessments will include progress and growth over the past year in the area of Socialization. Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019. All newly completed assessments will cover the progress and growth from the prior year. the Program Specialist will be responsible for ensuring this occurs. 11/30/2019 Implemented
2380.181(e)(13)(v)Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of recreation.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan. All assessments will include progress and growth over the past year in the area of Recreation. Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019. All newly completed assessments will cover the progress and growth from the prior year. the Program Specialist will be responsible for ensuring this occurs. 11/30/2019 Implemented
2380.181(e)(13)(vi)Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of community integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan. All assessments will include progress and growth over the past year in the area of community integration. Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019. All newly completed assessments will cover the progress and growth from the prior year. 11/30/2019 Implemented
2380.36(b)Staff #1 and #2 had late annual fire safety training. Training was held on 04-19-18 and then not again until 05-18-19.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The annual training was completed a month late. In order to ensure that this is completed annually per regulation, the responsibility has been assigned to the chair of the safety committee, Currently Nathan Rice, Internal Operations Manager. The fire safety training has been scheduled to occur on Friday, October 18, 2019. It has been rescheduled to coincide with National Fire Prevention month which occurs every October. If any staff or individuals are not in attendance on this day, the training will be completed for them by the end of October. 10/10/2019 Implemented
SIN-00138768 Renewal 08/02/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 had a TB test on 12/16/2015. He didn't have another TB test until 1/2/2018, which exceeds the requirement.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.The Program Specialist and DSP designee will ensure to look at the dates of past required immunizations in addition to the monitoring of the annual physical date to ensure that the immunizations are current. A chart with dates of current physical/TB/DT is currently utilized and will continue to be so with focus being placed on ensuring the physical/immunizations are completed within the allotted time frame. As the TB is only required every 2 years and DT every 10 years, minimum due dates for the immunizations will be added to the chart. 08/03/2018 Implemented
2380.181(a)Individual #1's assessment dated 12/12/17 was not updated from the previous year. All of the information was the same and it contained the same typos and misspellings.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.Assessments for each individual will be completed based on their current level of skill functioning with focus placed on progress made over the past year and their current needs. Templates for past years assessments will not be utilized to develop the assessment for the current year. all participants will have their annual and initial assessments completed with care to ensure that their current skill levels are accurately portrayed within the assessment. All assessments will be reviewed and signed off on by a minimum of 2 staff - Program Specialist and at least 1 DSP staff member. 08/03/2018 Implemented
SIN-00122620 Renewal 10/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)This information is not included on any of the physical exams for Individual #1 (7/19/2017), Individual #2 (1/16/2017), Individual #3 (12/6/2016), and Individual #4 (12/6/2016).The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.111(c)(10) - the physical exam was missing the statement Medical information pertinent to diagnosis and treatment in case of an emergency. This was added to the master physical form the date of inspection - October 19, 2017. updated copy of the physical was given to the inspector on this date. old copies of the physical have been disposed of. all future Physicals will be completed on the updated form. monitoring of the completed physicals will be completed by the Program Manager/Program Specialist -Elizabeth Cole. 10/19/2017 Implemented
2380.181(a)Individual #3 was admitted to this program on 1/10/2017. He did not have an initial assessment until 8/1/2017, which exceeds the 60 day 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.Individual #3 was participating in the program thru his regular school. he was funded by the school. there are currently no other school students participating in the program. individual #3 has since graduated and is participating through the waiver program. His assessment was completed within the 60 day requirement for the start of this funding. In the future, all individuals regardless of their funding stream will have an initial assessment completed within the 60 day requirement. the completion of the assessment will be reviewed and monitored by the CEO- Donald Black. 11/17/2017 Implemented
SIN-00100216 Renewal 11/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1's fire safety training was completed on 05/21/2015 and not again until 11/11/2016 (over 5 months late).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.the dates of fire safety training will be noted on one universal form. this form will be checked at monthly safety committee meetings to ensure that all individuals receive at minimum annual fire safety training. 12/22/2016 Implemented
2380.111(c)(3)Individual #2's Diphtheria/Tetanus immunizations were late. They were given on 06/19/06, then not again until 09-19-16 (3 momths late).The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Physicals for all individuals attending the ATF will be checked to ensure dates are within the timelines. This will be completed by the Program Specialist ¿ Elizabeth Cole. Completed on 12/22/2016.Long term plan ¿ as physicals are completed and turned into Serve, Inc, the dates will be checked by the Program Specialist and the Quality Manager to ensure timelines are met. Form will be developed to track physical dates and required immunization dates. To be completed by Elizabeth Cole, Program Specialist and Stacey Nybeck, Quality Manager. Form to be completed by 12/30/2016.A notice is sent to the individual's family/guardian a month prior to the physical due date. On this it notes the dates of the last physical/TB/DT on record and if the immunizations must be completed this year. If the immunizations are not completed by the due date, the individual/family and Supports Coordination will be notified that the individual will not be able to attend the program until such time that the immunizations are completed. Notification will be given by Elizabeth Cole, Program Specialist. 12/22/2016 Implemented
SIN-00082689 Renewal 09/24/2015 Compliant - Finalized
SIN-00068658 Initial review 09/17/2014 Compliant - Finalized