Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248187 Renewal 07/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.182(c)Individual #1's current assessment completed on 1/4/24, indicated they are unable to recognize poisons and that they are kept locked at the facility. However, Individual #1's individual plan last updated on 6/10/24, stated they have "an understanding of the handling and storage of poisonous substances, danger signs, and warning labels." In regard to fire evacuation, Individual #1's 1/4/24 assessment informed that they need complete assistance to do so while their 6/10/24 individual plan explained, Individual #1 "has fire safety awareness," and "knows to evacuate in the event of a fire." Lastly, Individual #1's 1/4/24 assessment indicated they are able to recognize dangerous heat sources but require supervision when around them. However, Individual#1's 6/10/24 individual plan left the safety skill domain of sensing and quickly moving away from dangerous heat sources unaddressed entirely.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Program Specialist will email Individual #1's SC and identify the areas that need updated in the current ISP, including understanding/handling poisons, fire evacuation and recognizing dangerous heat sources. A copy of the email will be kept for documentation in Individual #1's file. 07/26/2024 Implemented
SIN-00228607 Renewal 08/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2 had a physical examination on 2/10/2022 and then again on 3/07/2023.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialist will reach out to individual #1 staff/caregiver to see if there is any documentation explaining why the physical examination was not completed within the annual window. If documentation exists it will be kept on file 09/15/2023 Implemented
2380.111(c)(1)Individual #1's most recent physical examination, completed 11/30/2022, did not include a review of previous medical history. This section was left blank.The physical examination shall include: A review of previous medical history.Program Specialist will return the physical examination form to the individual/caregiver and ask that the missing information in the previous medical history section be completed or that an additional document reviewing the previous medical history be submitted as soon as possible. 09/15/2023 Implemented
2380.111(c)(5)Individual #1, date of admission 10/3/2022 had initial Tuberculin Skin Test completed on 12/2/2022.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.Program specialist requested documentation that a Tuberculin Skin Test was completed prior to 12/2/2022. Individual #1's staff were able to provide documentation the Individual #1 had a Tuberculin Skin Test completed on 11/7/2020. This documentation was provided to the inspectors and is kept on file at the facility. 09/15/2023 Implemented
2380.111(c)(7)Individual #1's most recent physical examination, completed 11/30/2022, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank.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.Program Specialist will return the physical examination form to the individual/caregiver and ask that the missing information in the health maintenance needs, medication regimen, and the need for blood work at recommended intervals be completed or that an additional documenting this information be submitted as soon as possible. 09/15/2023 Implemented
2380.111(c)(9)Individual #1's most recent physical examination, completed 11/30/2022, does not include contraindicated medication. This section was left blank.The physical examination shall include: Allergies or contraindicated medication.Program Specialist will return the physical examination form to the individual/caregiver and ask that the missing information in the contraindicated medication section be completed or that an additional document containing this information be submitted as soon as possible. 09/15/2023 Implemented
2380.111(c)(11)Individual #1's most recent physical examination, completed 11/30/2022, did not include special instructions for the individual's diet. This section was left blank.The physical examination shall include: Special instructions for an individual's diet.Program Specialist will return the physical examination form to the individual/caregiver and ask that the missing information in the special instructions for the individuals diet section be completed or that an additional document containing this information be submitted as soon as possible. 09/15/2023 Implemented
2380.39(c)(1)Chief Executive Officer #1 annual trainings for the training year 12/1/2021 through 11/30/2022 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals 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, individual choice and supporting individuals to develop and maintain relationships.Chief Executive Officer # 1 will complete trainings outlined in subsections (a) and (b) that encompass the application of person-centered practices, community integration, client choice, and supporting clients to develop and maintain relationships that were incomplete at the time of inspection. All other administrative staff will complete the twelve hours of training outlined in 55 PA Code 2380.39 (c) (1-5). Chief Executive Officer #1 and all other administrative staff will be added to the training calendar to ensure these trainings are completed on an annual basis. 09/15/2023 Implemented
2380.39(c)(3)Chief Executive Officer #1 annual trainings for the training year 12/1/2021 through 11/30/2022 did not encompass individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Chief Executive Officer # 1 will complete training on individual rights that was incomplete at the time of inspection. All other administrative staff will complete the twelve hours of training outlined in 55 PA Code 2380.39 (c) (1-5). Chief Executive Officer #1 and all other administrative staff will be added to the training calendar to ensure these trainings are completed on an annual basis. 09/15/2023 Implemented
2380.182(c)Individual #2's assessment, completed on 1/04/2022, was sent to the plan team on 1/04/2022 for the annual Individual Service Plan meeting held on 10/05/2022. The assessment was not reviewed and sent to the plan team within six months prior to the Individual Service Plan meeting. Individual #3's assessment, completed 1/28/2022 was sent to the plan team on 1/31/2022 for the annual Individual Service Plan meeting held on 11/15/2022. The assessment was not reviewed and sent to the plan team within six months prior to the Individual Service Plan meeting.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Program Specialists will review the assessments for Individual #2 and Individual #3 and make any necessary updates or changes. The updated assessments for both Individual #2 and Individual #3 will be emailed/sent to all team members so that everyone has a current copy of the assessment. Program Specialist will keep and print a copy of the email sent in order to document the review was completed. 09/15/2023 Implemented
SIN-00191783 Renewal 08/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.88(f)The fire extinguisher mounted on the wall next to the exit door leading to the Customer Area was most recently inspected in 10/2019.Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher.The fire extinguisher was removed from the wall and put into storage until it can be inspected by a fire safety expert. An inspection of the fire system and extinguishers has been scheduled for September 8, 2021. 09/03/2021 Implemented
2380.89(c)The written fire drill record for the fire drill conducted 9/11/2020 did not document whether the fire alarm was operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.The fire drill record for the drill conducted on 9/11/2020 will be updated/corrected to show that the fire alarm was operative at the time of the fire drill. 09/10/2021 Implemented
2380.111(c)(3)Individual #2's most recent Tetanus immunization was completed on 4/25/2011.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.WCBA has received documentation that Individual#2 is scheduled to receive the Tetanus immunization on 9/17/21. We have also learned that the delay in getting the immunization was due to Individual # 2 needing a Covid-19 booster. Program Specialists will review physicals of all other individuals attending the ATF to ensure the violation does not exist elsewhere. 09/10/2021 Implemented
SIN-00175954 Renewal 09/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)Individual #2's physical examination completed 7/28/20 did not include an assessment of the individual's health maintenance needs. This section was blank.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.Program Specialist will make an attempt to get the missing information completed on the existing physical form. Moving forward the ATF Program Specialist will review all physical forms to ensure that they are completed in full. If the ATF Program Specialist finds there is information missing the physical form will be returned to the individual to be corrected. [The program specialist has returned the physical examination forms to the individuals/families for the missing information to be completed. The forms have not been returned. The program specialist shall follow up to ensure physical examination documentation is completed as required. The program specialist reviewed all individuals current physical examination forms to ensure all information was included. Upon completion and submission, the program specialist shall audit all individuals' physical examination documentation to ensure all required information is included and health services are arranged and provided. Missing information shall immediately be completed by following the agency's procedures and protocols. Documentation of all audits of individuals' physical examination forms shall be kept. (DPOC by AES, HSLS on 10/7/20)] 09/30/2020 Implemented
2380.111(c)(10)Individual #1's physical examination completed 5/14/19 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. Individual #2's physical examination completed 7/28/20 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist will make an attempt to get the missing information completed on the existing physical form. Moving forward the ATF Program Specialist will review all physical forms to ensure that they are completed in full. If the ATF Program Specialist finds there is information missing, the physical form will be returned to the individual to be corrected.[The program specialist has returned the physical examination forms to the individuals/families for the missing information to be completed. The forms have not been returned. The program specialist shall follow up to ensure physical examination documentation is completed as required. The program specialist reviewed all individuals current physical examination forms to ensure all information was included. Upon completion and submission, the program specialist shall audit all individuals' physical examination documentation to ensure all required information is included and health services are arranged and provided. Missing information shall immediately be completed by following the agency's procedures and protocols. Documentation of all audits of individuals' physical examination forms shall be kept. (DPOC by AES, HSLS on 10/7/20)] 09/30/2020 Implemented
2380.111(c)(11)Individual #1's physical examination completed 5/14/19 did not include special instructions for an individual's diet. This section was blank.The physical examination shall include: Special instructions for an individual's diet.Program Specialist will make an attempt to get the missing information completed on the existing physical form. Moving forward the ATF Program Specialist will review all physical forms to ensure that they are completed in full. If the ATF Program Specialist finds there is information missing the physical form will be returned to the individual to be corrected.[The program specialist has returned the physical examination forms to the individuals/families for the missing information to be completed. The forms have not been returned. The program specialist shall follow up to ensure physical examination documentation is completed as required. The program specialist reviewed all individuals current physical examination forms to ensure all information was included. Upon completion and submission, the program specialist shall audit all individuals' physical examination documentation to ensure all required information is included and health services are arranged and provided. Missing information shall immediately be completed by following the agency's procedures and protocols. Documentation of all audits of individuals' physical examination forms shall be kept. (DPOC by AES, HSLS on 10/7/20)] 09/30/2020 Implemented
SIN-00156078 Renewal 05/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The fire drill held on 10/22/18 at 1:35PM had an evacuation time of 2 minutes 42 seconds. The fire drill held on 3/19/19 at 10:15AM had an evacuation time of 2 minutes 37 seconds. The fire drill held on 4/29/19 at 1:45PM had an evacuation time of 2 minutes 49 seconds. The facility does not have an extended evacuation time specified by a fire safety expert.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.We have reached out to the local fire safety expert and have not received a phone call back. In the meantime we have assigned more staff to help some of the more challenging individuals out of the building. We will evacuate the building within 2 minutes and 30 seconds each month for the remainder of the year or until we obtain an extended letter of evacuation with a new time of evacuation. May 2019 2:12 minutes June 2019 2:01 minutes 07/03/2019 Implemented
2380.113(a)Program Specialist #1 had a physical examination completed 8/30/16 and then again 1/27/19.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.All staff who need a physical and TB test have a current one. I was not able to go back and re-create a physical that was past due. There is a chart that will be followed to ensure this does not happen again and will be monitored on a monthly basis by Director of Programs. [Names and dates of physical examinations were removed for the plan of correction for the privacy of the staff persons. Immediately, the CEO or designee shall develop and implement a notifications system to alert employees of when their physical examinations are due and follow up to ensure timely completion and update the aforementioned chart upon completion. Documentation of the process shall be kept. (DPOC by AES,HSLS on 7/3/19)] 07/03/2019 Implemented
SIN-00115941 Renewal 06/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)Direct Service Worker #1 had a Tuberculin skin test completed 1/18/15 and then again 2/9/17. The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.A spreadsheet has been developed listing the staff's last TB test and physical. The Human Resource coordinator will be responsible to give the staff a reminder their TB test and physical are due at least 30 days prior to expiration. The director of programs will monitor to ensure the paperwork is submitted on time. [Within 30 days of receipt of the plan of correction, the Director of Program shall train the Human Resource Coordinator on completing and updating the tracking spreadsheet to ensure staff have physical examination including Tuberculin skin testing completed, timely. Documentation of the training shall be kept. At least monthly for 6 months and then continuing quarterly, the Director of Programs shall review the aforementioned spread sheet to ensure completion and updates as needed to ensure staff physical examinations including Tuberculin skin testing is completed, timely. Documentation of the reviews shall be kept. (AS 7/6/17)] 06/29/2017 Implemented
SIN-00092575 Renewal 06/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)The physical examination, completed 2/3/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination, completed 2/2/16 for Individual #2, medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The program specialist will review all current physical forms we have on file for the consumers attending the Adult Training Facility. If there are blanks on any area including the Medical information pertinent to diagnosis and treatment in case of emergency, the program specialist will request these blanks be completed. This may take some time to get accomplished, but letters will be sent by 6/19/16 of all affected consumers. In the future, the program specialist and program director will review these physicals to ensure we are in compliance with all areas needed during the physical examination. [Individual #1's physical examination was updated to address medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination was updated to address medical information pertinent to diagnosis and treatment in case of an emergency. Upon completion and prior to entering in the individuals' records the aforementioned reviews of physical examinations by the program director and program specialist shall be completed and missing information obtained. Documentation of reviews shall be kept. (AS 7/7/16)] 06/19/2016 Implemented
2380.111(c)(11)The physical examination, completed 2/2/16 for Individual #2 did not include special instructions for the individual's diet. The physical examination, completed 4/26/16 for Individual #4, did not include special instructions for the individual's diet. The physical examination shall include: Special instructions for an individual's diet.The program specialist will review all current physical forms we have on file for the consumers attending the Adult Training Facility. If there are blanks on any area including special instructions for an individual's diet, the program specialist will send a letter to the responsible person and request these blanks be completed. This may take some time to get accomplished, but letters will be sent by 6/19/16 of all affected consumers. In the future, the program specialist and program director will review these physicals to ensure we are in compliance with all areas needed during the physical examination.[Individual #4's physical examination was updated with special instructions of the individual's diet. Individual #2's physical examination was updated with "no restrictions" for special instructions for individual's diet. Upon completion and prior to entering in the individuals' records the aforementioned reviews of physical examinations by the program director and program specialist shall be completed and missing information obtained. Documentation of reviews shall be kept. (AS 7/7/16)] 06/19/2016 Implemented
2380.181(e)(14)The assessment completed 1/4/16 for Individual #1 did not include the individual's knowledge of water safety and ability to swim. The assessment completed 1/4/16 for Individual #2 did not include the individual's knowledge of water safety and ability to swim. The assessment completed 1/4/16 for Individual #3 did not include the individual's knowledge of water safety and ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.All consumers attending the Adult Training Facility will have an assessment that includes their knowledge of water safety and ability to swim. The Program Specialist will review all files to make sure the proper assessment was used in 2016. For all consumers found not to have this information included in the annual assessment, the Program Specialist will send an addendum page to the team. The Program Director will review all annual assessments to be completed for 2017 to ensure this question is addressed and this compliance is followed.[Individuals #1, #2 and #3s' assessments were updated to include the individual's knowledge of water safely and ability to swim on 6/15/16. Documentation of assessment reviews by the program director shall be kept. (AS 7/7/16)] 06/19/2016 Implemented
SIN-00074162 Renewal 05/14/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(8)(iv)The plan team members for Individual #1, Individual #2, Individual #3, Individual #4, and Individual #5, were not notified of the option to decline the ISP review documentation.Each individual¿s record must include the following information: Documentation of ISP reviews and revisions under §  2380.186 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation.Decline notification has been added to ISP [As per conversation with Program Specialist on 7/14/15, PS added a notification to decline on the 3 month ISP reviews and documentation which was sent to Individual #1, #2, #3, #4 and #5 to all plan team members. The master copy of the 3 month reviews documentation was changed do include the option to decline and going forward this copy will sent to plan team members for all Individuals with the next ISP review. (AS 7/15/15)] 06/06/2015 Implemented
2380.181(f)The assessments for Individual #1, completed 3/27/15, Individual #2, completed 1/30/15, Individual #3, completed 1/30/15, Individual #4, completed 1/2/15, and Individual #5, completed 1/2/15, were not sent to all of the plan team members.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).Assessments will be sent to all on invitation list. [As per conversation with PS, the program specialists reviewed all individual records including ISP and invitation letters from SC and put a list the plan team members on the "important information sheet" to reference when sending assessments for all individuals. The program specialists will review each ISP invite letter annually to ensure all plan team members are included and receive a copy of the assessment. (AS 7-14-15)] 06/06/2015 Implemented
2380.186(d)The 3 month ISP review documentation for Individual #1, completed 3/27/15, was not sent to all plan team members. The 3 month ISP review documentation for Individual #2, completed 1/30/15 and 3/26/15, was not sent to all plan team members. The 3 month ISP review documentation for Individual #3, completed 1/30/15 and 3/26/15, was not sent to all plan team members. The 3 month ISP review documentation for Individual #4, completed 7/7/14, 10/7/14, 1/7/15, and 4/1/15, was not sent to all plan team members. The 3 month ISP review documentation for Individual #5, completed 7/2/14, 10/2/14, 1/2/15, and 4/16/15, was not sent to all plan team members. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.All ISP's will be sent to list of team members on invitation list. [As per conversation with PS on 7/14/15, the program specialists reviewed all individual records including ISPs and invitation letters from SC and put a list the plan team members on the "important information sheet" to reference when sending 3 month ISP reviews for all individuals. The program specialists will review each ISP invite letter every 3 months to ensure all plan team members are included and receive a copies of the of the 3 month reviews. (AS 7-14-15)] 06/06/2015 Implemented
SIN-00058307 Renewal 05/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(3)The physical dated 9/7/12 did not include a signed statement indicating that Staff #1 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.An attached letter to all physicals stating that physicals must be filled out in its entirety. WCBA will not accept any physicals that aren't filled out completly. Employee's will not start until physicals are correct. [All physical forms of current staff will be audited to ensure that they contain all required components within 30 days of receipt of the plan of correction. (CHG 8/5/14)] 06/10/2014 Implemented
2380.177Individual #2 did not sign the consents to release information. There is no documentation stating that Individual #2 has a guardian and that the individual has been deemed incompetent. Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.A letter will be attached to hiring packet and placed in file that all coonsumers must sign their paperwork themselves, unless they have a guardian or are deemed incompetant. All staff have been notified. [Written consent from individual #2 or his/her parent or guardian if the individual is incompetent will be obtained within 30 upon receipt of the plan of correction. (CHG 8/5/14)] 06/10/2014 Implemented
2380.181(f)The Program Specialist did not provide the annual assessment for Individual #2 to the SC or team members at least 30 days prior to the ISP meeting.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).A form was added to assessment stating date sent, team members to be mailed and who was mailed the assessment. 06/10/2014 Implemented
2380.186(d)There is no documentation indicating that the Program Specialist provided the ISP review to the SC and plan team members within 30 days after the ISP review meeting. Individual #1, 3/6/14, 12/6/13, 9/6/13, 6/6/13; Individual #2, 1/24/14, 10/25/13, 7/26/13 and 4/26/13.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.A form was added to ISP stating date sent, team members who should receive copies and members who were sent copies. 06/19/2014 Implemented
SIN-00268607 Renewal 06/24/2025 Compliant - Finalized
SIN-00209189 Renewal 08/04/2022 Compliant - Finalized
SIN-00135887 Renewal 05/31/2018 Compliant - Finalized
SIN-00044930 Renewal 01/28/2013 Compliant - Finalized