Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290091 Renewal 06/01/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(2)There was no TB test record on file at the time of the inspection for Staff Member 2.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.Unfortunately, Staff #2 is on an extended medical leave of absence due to an unrelated issue requiring surgery and an extensive recovery. Prior to Staff #2 returning to work at the Father Bill Atkinson Center (FBAC), Staff #2 will provide evidence of a successful TB test. The FBAC CEO and Program Director conducted a review of all Staff medical examinations and all had TB tests except Staff #2. 06/29/2026 Implemented
2380.113(c)(3)The annual physical for Staff Member 2 did not note if the staff was free from 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.Staff #2's medical examination included a signed and dated statement from the physician: "I have examined the person herein described and have reviewed his/her health history. It is my opinion that he/she is free of communicable diseases and is capable of serving FBAC clients." Please see Enclosure 113c3. 06/29/2026 Implemented
2380.181(a)Individual 1 and 2's initial assessments were completed more than 60 days after admission date. Individual 1's admission was 10/27/2025, assessment is dated 02/03/2026. Individual 2's admission was 03/17/2026, and their initial assessment is dated 05/27/2026.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 #1 and Individual #2 assessments were conducted late, by 39 days and 11 days, respectively. The Member Intake checklist, Enclosure 181, was revised and reviewed with the FBAC Program Director and Operations Director to ensure future adherence to the timelines required for assessments. As noted on Enclosure 181a, FBAC successfully conducted an assessment with a new Member (Individual) on June 8, 2026, 31 days after admission, within the 60 day window. 06/29/2026 Implemented
2380.181(e)(10)Individuals 1 and 2 did not have lifetime medical history on file.The assessment must include the following information: A lifetime medical history.The FBAC Lifetime Medical History Form, Enclosure 181e10, was created based on the 2380.181(e)(10) requirements and guidance from Philadelphia Coordinated Healthcare (PCHC). The FBAC Individual Assessment Form, Enclosure 181, was revised to require attachment of the Lifetime Medical History and to require update if the individual's medical situation changed since the last assessment. The Lifetime Medical History will be required for each member before the start of our Fall session in September 2026. Enclosure 181e10ex is an example of the form filled out for one of FBAC's members to demonstrate compliance. Also, the FBAC Member Intake Checklist (enclosed) was revised to explicitly require a Lifetime Medical History for new members. 06/29/2026 Implemented
2380.37(a)Staff members 1 and 2 did not complete the required training to include the length of trainings, copies of certificates received and persons attending either through instructor lead or on-line support as communicated at the time of the inspection.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.As noted, the training records for Staff members #1 and #2 did not include the length of trainings, copies of certificates, or validation / verification of training for instructor led courses. Staff members #1 and #2 did complete the required Father Bill Atkinson Center (FBAC) training, covering 24 hours of material through a combination of instructor led sessions and self-study. To correct these deficiencies, the FBAC Staff Training Record form has been revised for the upcoming 2026-2027 training year, Enclosure 37a. The revisions reflect a change in the training calendar and specifically identify the training content, source, length, delivery method, duration, and completion date for each module. 06/29/2026 Implemented
SIN-00282194 Renewal 09/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)2380.20(a)The criminal history clearance for Staff number 1 (dated 7/11/25) was completed more than 5 working days after date of hire (DOH 7/1/25).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.Staff #1's start date provided to PA ODP was in error. Staff #1 started on September 3, 2025. Staff #1's PA criminal clearance check was performed on July 11, 2025. This information was provided to PA ODP on the day of the inspection, September 26, 2025, via email to K. Smith and V. Brown. To prevent administrative errors in the future, the FBAC Staff Hiring and Onboarding Checklist (enclosed) was revised and reviewed with the Business Operations Director and Program Director. The Business Operations Director is responsible for ensuring accurate start date information is recorded. 06/12/2026 Implemented
2380.20(b)The attestation of residency (signed 10/30/24) was completed more than 5 working days after date of hire (9/1/24) for number 2. During the date of inspection (9/26/25) the staff files for staff #1 and Staff #3 did not contain completed FBI clearance or residency attestation.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.Staff #2 was hired after Father Bill Atkinson Center started operating in January 2024 and shortly before the first inspection for the Father Bill Atkinson Center (FBAC) on September 27 2024. At that inspection, FBAC was cited for not having PA Residency Attestations for its employees. Subsequently, FBAC had all its staff submit attestations, including Staff #2. In addition, FBAC implemented the Staff Hiring and Onboarding Checklist. Residency Attestations were provided to PA ODP on the day of inspection, September 26, 2025, via email to K. Smith and V. Brown. Those attestations are resubmitted as enclosures. 06/12/2026 Implemented
2380.89(e)Alternate exit routes were not used during the fire drills.Alternate exit routes shall be used during fire drills.The Father Bill Atkinson Center implemented use of alternate exits at the next fire drill on October 29, 2025. Since the inspection on September 26, 2025, FBAC fire drills have used five different exits. Please see enclosure. This training ensures staff and members (clients) are familiar with alternate routes out of the building. 06/12/2026 Implemented
2380.89(f)On 9/26/25, the fire drill record presented did not document if there were any problems encountered or if the fire alarm was operable during the drill. The facility did not hold fire drills on different days of the week. The fire drill record shows fire drills conducted from Jan 2025 until May 2025 occurred on the last Monday of each month.Fire drills shall be held on different days of the week and at different times of the day.The Father Bill Atkinson Center strives to be compliant with the fire safety regulations and to conduct realistic fire drills monthly. As a result of the inspection on September 26, 2025, the FBAC CREC Fire Drill Record (enclosed) was revised to include a field for problems encountered during the drill. As that document shows, FBAC has subsequently recorded any problems encountered during the drills. FBAC only operates for nine hours each week, on Monday, Wednesday, and Friday from 1 to 4pm. On many of those days, the FBAC is out in the community, particularly Wednesdays. As the enclosed Fire Drill record shows, for the 23 fire drills conducted, 9 were on Mondays, 9 were on Fridays, and 5 were on Wednesdays, a reasonable, random distribution of days. For the times of the drill, 3 were in the first hour, 8 in the 2nd and 12 were in the 3rd. Again, this is a reasonable distribution of times, given our limited time of operations. However, we will conduct more drills in the first hour in the future to be more balanced. The FBAC Fire Safety policy (enclosed) has been revised to explicitly require different days of the week and times to the extent possible. This has been reviewed with the Program Director to ensure continued compliance. 06/12/2026 Implemented
2380.111(c)(2)The physical presented on file dated 9/2/25 for staff #3 and 1/30/24 for staff #5 did not include Tuberculin skin testing results.The physical examination shall include: A general physical examination.The violation Description for refers to staff physical examinations and is identical to the violation Description for 2380.113(a). Based on the paragraph number, 2380.111(c)(2), and the Correction Required: "The physical exam shall include: A general physical examination," I assume there must be an issue with the physicals provided for the two individuals. However, the enclosed physical examinations for Individual #1 and Individual #2 are complete general physical examinations. The examinations include signed statements from the respective Examining Physicians that states: "I have examined the person herein described and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in FBAC program activities, except as noted above." 06/12/2026 Implemented
2380.113(a)The physical on file presented for Staff #6 was not completed prior to hire date (1/20/24). The physicals observed on file for staff 3 was not completed prior to hire date (7/2023).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.The physical exam for Staff #6 was completed on 5/20/24, after the hire date of 1/20/24. The physical exam for Staff #3 was completed 8/14/2025, after the hire date of 1/20/25. Both are violations of the requirement to have staff physical exams within 12 months prior to start of employment. Following the inspection on September 26, 2025 the Staff Hiring and Onboarding checklist (Enclosure 20ab) was revised to explicitly require staff physicals be completed prior to start date. This was successfully implemented for all hires, a total of two, since the inspection. This is demonstrated by Enclosure 113ac2 which shows the completed physical exam dated 5/2/2025 for an employee hired in October 2025. 06/12/2026 Implemented
2380.113(c)(2)The physical presented on file dated 9/2/25 for staff #3and 1/30/24 for staff #5 did not include Tuberculin skin testing results.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.Staff #6 physical exam dated 9/2/2025 did not have a TB test and Staff #5 physical exam dated 1/30/24 did not have a TB test. Both were violations of the requirement to have a negative tuberculin test as part of the physical exam. After the inspection on September 26, 2025 the Staff Hiring and Onboarding checklist (Enclosure 20ab) was revised to explicitly require TB testing be completed prior to start date. This was successfully implemented for all hires, a total of two, since the inspection. This is demonstrated by Enclosure 113ac2 which shows the completed physical exam dated 5/2/2025 with a negative TB test for an employee hired in October 2025. 06/12/2026 Implemented
2380.21(l)On 9/26/25, the provider did not present verification that quarterly conversations were held with Michael Malloy and Alfred Berger relating to their preferred community participation and activities as required by ODP Announcement 24-061.An individual has the right to make choices and accept risks.Following the inspection on September 26, 2025, Father Bill Atkinson Center implemented quarterly discussions with each member (client) to discuss what activities they want the group to do in the community. These discussions are now a regular part of the FBAC schedule and activity planning process. Enclosed are the quarterly discussions with Individuals #1 and #2 for Q4 2025, Q1 2026, and Q2 2026. 06/07/2026 Implemented
2380.36(b)On the day of inspection (9/26/25), the facility did not have written documentation that Staff #4 staff were trained annually in fire safety nor documentation of fire safety training being completed by a fire safety expert was not presented during the inspection for staff 4, 5, and 6.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).On the day of inspection, 9/26/2025, no documentation was available to demonstrate fire safety training for Staff #5 or Staff #6. The inability to produce adequate documentation of fire safety training was in violation. Staff #6 was trained in fire safety by a fire safety expert in November 2024. Please see Enclosure 36b.1. However, the inability to produce this documentation was in violation. Shortly after the inspection, the Father Bill Atkinson Center had its annual fire safety training at the Newtown Square Fire Department with the Fire Chief Christopher Young on October 17, 2025. Staff #6 was in attendance. Please see Enclosures 36b.2,3, and 4. Staff #4 is not a program specialist or a direct service worker and does not require annual fire safety training. To ensure compliance with 2380.36b going forward, the Program Director will keep more rigorous documentation. An attendance sheet with description of the training signed by attendees and Fire Chief Young will document the annual training. In addition, any staff not able to attend the in-person training will be required to take online fire safety training. 06/12/2026 Implemented
2380.37(a)On the day of inspection (9/26/25), the facility presented a documentation for annual training that did not designate the length of training hours received for staff ).Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Subsequent to the inspection on September 26, 2025, the Father Bill Atkinson Center revised its training documentation to include hours required to complete the coursework. Please see Enclosure 37a that demonstrates this for two employees hired after the inspection. 06/12/2026 Implemented
SIN-00253474 Renewal 09/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(b)There are no 2-year attestations for new employees asking if they have lived in the state of PA for the past two years upon hire to determine if FBI checks need to be done in addition to the PA criminal history record check.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.In October 2024 the FBAC Operations Director created a Residency Attestation form for employees to attest whether they have lived in Pennsylvania for the previous two years and incorporated it into a revised hiring process. New employee Molly Dagit filled out the form (Enclosure 20b.1) as part of the revised process. Molly Dagit started October 30, 2024. In addition, the FBAC Program Manager sent all existing employees the attestation form and received the forms back on November 1, 2024. Please see Enclosure 20b.1. All employees have lived in Pa for over two years. If any of the attestation forms indicate otherwise and the employee did not have an FBI clearance check on file, an FBI check would be initiated. 11/01/2024 Implemented
2380.70(a)There was no provision for the first aid area to be separated by partition or privacy screen from program areas.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.On October 28, 2024, the FBAC Program Manager confirmed with the Haverford CREC facility manager that an adjacent, unoccupied room could be used as the first aid area. In the event of need for a first aid area, the can be quickly set up to provide privacy, separated from the program area. 10/28/2024 Implemented
2380.70(b)The first aid area did not contain a bed or cot, a blanket, and a pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.On October 28, 2024, the FBAC Program Manager purchased a cot, blanket, pillow, complete first aid kit and stored them in the Haverford CREC facility. In the event of the need for first aid, these items are easily accessible in a room adjacent to, but private from the program. 10/28/2024 Implemented
2380.111(a)Individual #1 did not have a physical prior to their 1/8/24 admission date. The first physical received is dated 9/10/24.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.On October 29, 2024, the FBAC Program Manager confirmed that all members have submitted Physical Examination forms. In addition, the FBAC CEO, Operations Director, and Development Director created the FBAC Member Intake Checklist, Enclosure 181.3, to explicitly call out the need for completed medical forms prior to joining FBAC. 10/29/2024 Implemented
2380.111(c)(5)There is no record of individual #1 having a TB test with a negative result prior to being admitted to the program.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.On October 27, 2024, FBAC Program Specialist / Development Director requested Individual #1 to submit TB tests results. If their TB test results are not readily available, Individual #1 will schedule an appointment to get them no later than December 1, 2024. On October 29, 2024, the FBAC Program Manager confirmed that 11 members have TB test results and 3 do not. For those members without TB test results, they are required to provide them by December 1, 2024. 10/29/2024 Implemented
2380.111(c)(6)The 6/7/24 physical for Individual #2 does not indicate if the individual is free from communicable diseases. Both the yes and no boxes were left blank on the form.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.On October 27, 2024, FBAC Program Specialist / Development Director requested Individual #2 to submit a completed Individual Physical Examination form, including the communicable disease section, no later than December 1, 2024. On October 29, 2024, the FBAC Program Manager confirmed that 11 members' physical examination have indicated the individual is free from communicable diseases, and 3 members left that section blank. For members with incomplete Physical Examination forms, they must submit a completed form no later than December 1, 2024. 10/29/2024 Implemented
2380.111(c)(10)The 6/7/24 physical for individual #2 does not include information pertinent to diagnosis and treatment in case of emergency. The area designated for this information on the physical form was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.On October 27, 2024, FBAC Program Specialist / Development Director requested Individual #2 to submit a completed Individual Physical Examination form, including the information pertinent to treatment during emergencies, no later than December 1, 2024. On October 29, 2024, the FBAC Program Manager confirmed that 11 members' physical examination have filled out the section with information pertinent to emergencies, and 3 members did not. For members with incomplete Physical Examination forms, they must submit a completed form no later than December 1, 2024. 10/29/2024 Implemented
2380.113(a)There is no physical on file for staff #2 whose date of hire was 1/8/24.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.On October 29, 2024, the FBAC Program Manager confirmed that all active staff have submitted Physical Examination forms. Staff #2 is no longer employed by FBAC. 10/29/2024 Implemented
2380.181(a)The assessment for individual #1 is missing acquisition of functional skills, communication, personal adjustment, and personal needs with or without assistance information. There are no details regarding progress over the last 365 calendar days to determine actual progress.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.On October 30, 2024, the FBAC Program Specialist conducted assessments of two new members (individuals), Enclosures 181a.1 and 181a.2. These individuals started with FBAC on September 6, 2024. The assessments were conducted within the 60 day window and more detailed information was provided for each individual. Subsequent annual assessments for other members will also provide detailed information. 10/30/2024 Implemented
2380.21(u)The individual rights for individual #1 were not reviewed upon admission on 1/8/24. They were first reviewed 9/3/24.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.On October 29, 2024, the FBAC Program Manager confirmed that all members have submitted signed Individual Rights Review forms. In October 2024, the FBAC CEO, Operations Director, and Development Director revised the FBAC Member Intake process documentation to explicitly require the Individual Rights Review form be signed by new members prior to joining FBAC. 10/30/2024 Implemented
2380.36(a)There is no record of staff #1 receiving fire safety training.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.On October 30, 2024, the FBAC Program Specialist completed fire safety training. Also on October 30, 2024, the FBAC Operations Director confirmed that all direct support staff have been trained on fire safety. 10/30/2024 Implemented
2380.36(b)There is no record of Staff #2 receiving fire safety training. Staff #2's recorded date of hire is 1/8/24.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).As noted above, On October 30, 2024, the FBAC Operations Director confirmed that all direct support staff have been trained on fire safety. Staff #2 is no longer employed by FBAC. 10/30/2024 Implemented
SIN-00230676 Initial review 08/31/2023 Compliant - Finalized