Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257952 Renewal 12/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Direct Service Worker (DSW) #1, date of hire 07/05/24, had a criminal history record check completed on 07/25/24. This exceeds the within 5 working days requirement.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 When receiving and reviewing an employment application, the next step in the hiring process will be obtaining a criminal background check prior to any training. Only after receiving and reviewing the criminal background check will the potential employee complete and finish the next steps in the hiring process to work with individuals alone. 01/06/2025 Implemented
2380.111(c)(3)Individual #2's most recent physical examination, dated 7/31/24, did not contain a recent tetanus, diphtheria, and pertussis (Tdap) immunization. Tdap booster shots are recommended by the United States Public Health Service, Center for Disease Control every 10 years.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.As of 12/19/24, all enrolled individuals¿ physical records were reviewed for compliance in immunizations as recommended by the United States Public Health Service, Centers for Disease Control 2380.111 (c) (3). Individual #1 will have the immunization completed on or about 1/16/2025. 01/01/2025 Implemented
2380.21(u)Individual #1, date of admission 09/12/22, was informed and explained individual rights on 09/07/23 and then again on 09/12/24. This exceeds the annual 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.As of 1/7/25, all enrolled individuals¿ records have been reviewed to ensure compliance with individual rights 2380.21(u). All individual's records have been reviewed for compliance with Individual rights and Individual rights annual date. 01/07/2025 Implemented
SIN-00218767 Renewal 02/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's physical examination completed 10/04/2022 did not include immunizations. Individual #3's physical examination completed 8/22/2022 did not include immunizations. Individual #4's physical examination completed 7/08/2022 did not include immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Future physical examinations for individuals who attend the day program will have a list of current immunizations and the date immunization was administered. Administration/staff that receive physical examinations prior to an individual attending will be trained to check that the physical examination ensures all components are completed in their entirety, as required by 2380.111(c)(3) by the United States Health Service, Center for Disease Control, Atlanta, Georgia 30333 02/12/2023 Implemented
2380.111(c)(4)Individual #3's physical examination completed 8/22/2022 did not include vision and hearing screening, as recommended by the physician. Individual #4's physical examination completed 7/08/2022 did not include vision and hearing screening, as recommended by the physician.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Future physical examinations will have a vision and hearing recommended by the physician listed on the physical examination. TracyJo's now requires that our physical be completed in its entirety by the individual's physicians, as required by 2380.111(c)(4). We will no longer accept the annual physical examination from the group home. 02/12/2023 Implemented
2380.111(c)(5)Individual #4, date of admission 9/17/2021, does not have documentation of having a Tuberculin skin test with negative results or an initial chest-Xray with results noted.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.Future annual physical examinations for individuals will be completed on our facility's physical examination documentation record. Tuberculin skin test with negative results or an initial chest x-ray with results noted will be conducted as required by 280.111(c)(5) 02/12/2023 Implemented
2380.111(c)(7)Individual #3's physical examination completed 8/22/2022 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.TracyJos has developed our own physical examination record. Future physical examinations must be completed on our facility's physical examination record for all individuals who intend to enroll in the day program. Assessment of the individual's health mountainous needs, medication regimen, and the need for blood work at recommended intervals listed on our physical exam required by 2380.111(c)(7) 02/12/2023 Implemented
2380.111(c)(8)Individual #1's physical examination completed 10/04/2022 did not include physical limitations of the individual. Individual #3's physical examination completed 8/22/2022 did not include physical limitations of the individual. Individual #4's physical examination completed 7/08/2022 did not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual.Future physical examinations for individuals that choose to enroll in day program will have physical limitations on their physical examination record before attending. TracyJo created and revised our physical examination document; we now require that our facility physical examination be completed in its entirety before the individual can attend, as required by 2380.111(c)(8) 02/12/2023 Implemented
2380.111(c)(9)Individual #4's physical examination completed 7/08/2022 did not include allergies or contraindicated medication. It was blank.The physical examination shall include: Allergies or contraindicated medication.In the future, all components of a physical examination will be completed. Allergies or contraindicated medication will be listed and completed by the individual medical professional before an individual can attend the day program required by 2380.111(c)(9) 02/12/2023 Implemented
2380.111(c)(10)Individual #4's physical examination completed 7/08/2022 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.All individual physical examinations will include medical information pertinent to diagnosis and treatment in case of an emergency. Our facility no longer excepts group home physicals. TracyJo has updated our facility's Individual physical examination that reflects all components required by 2380.111(c)(10) 02/10/2023 Implemented
2380.111(c)(11)Individual #4's physical examination completed 7/08/2022 did not include special instructions for an individual's diet. It was blank.The physical examination shall include: Special instructions for an individual's diet.Future individual physical examinations will be completed on our facility physical examination record, which has been updated and reflects all required components. Individual physical examinations will have special instructions for an individual's diet required by 2380.111(c(11) 02/10/2023 Implemented
2380.181(e)(4)Individual #1's assessment completed 11/21/2022 did not include the individual's need for supervision at the program. Individual #2's assessment completed 8/03/2022 did not include the individual's need for supervision at the program. Individual #3's assessment completed 10/12/2022 did not include the individual's need for supervision at the program. Individual #4's assessment completed 10/03/2022 did not include the individual's need for supervision at the program.The assessment must include the following information: The individual¿s need for supervision.All assessments are being reviewed to ensure compliance throughout all files. Individuals' need for supervision at the program is being checked and added to any assessments that are missing this component of the assessment, as required by 2380.181(e)(4) 02/28/2023 Implemented
2380.21(u)Individual #4, date of admission 9/17/2021, was informed and explained his individual rights on 3/01/2022 and not prior.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 two most recent Individual rights will be kept in the individual's record. Individuals and persons designated by the individual will have their individual rights informed and explained to them upon admission and annually thereafter. All individual records are being reviewed to ensure compliance required by 2380.21(21)(u) 02/28/2023 Implemented
2380.36(b)Direct Service Worker #1's fire safety training 12/19/2022 was not conducted by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).A fire safety expert will train all staff annually as required by 2380.36(36)(b). This will be conducted by video. All staff fire safety expert training is being added to the staff training. 02/28/2023 Implemented
2380.37(a)Fire safety training documentation from 3/04/2022 did not include the persons who attended. Therefore, compliance could not be measured that Direct Service Worker #2, Direct Service Worker #3, Direct Service Worker #4, and Program Specialist #5 attended the training.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.The training log will be revised and updated to show a list of staff that were in attendance for fire safety training, training source, content, dates, length of training, copies of certificates received, required by 2380.37(a) 02/28/2023 Implemented
2380.125(f)Individual #1 is prescribed Abilify for mood and aggression and Depakote for behaviors. Individual #1's individual support plan, last updated 10/20/2022, did not include a written protocol to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Create social, emotional, and environmental needs plans for individual #1. Contacted his S.C. for input and let her know this will need to be added to individual #1 I.S.P, required by 2380.125(f) 02/28/2023 Implemented
SIN-00200913 Renewal 03/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Direct Service Worker #1, date of hire 5/03/2021, had an application for a Pennsylvania criminal history record check submitted to the State Police on 7/28/2021. This exceeds the 5 working days allotted after the person's date of hire. Direct Service Worker #2, date of hire 3/08/2021, had an application for a Pennsylvania criminal history record check submitted to the State Police on 3/19/2021. This exceeds the 5 working days allotted after the person's date of hire.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.Future Pa record checks will be completed prior to the staff date of hire. [Within 30 calendar days of receipt of the Directed Plan of Correction, Staff responsible for submitting the application for a Pennsylvania criminal history check shall be trained in the requirement that the application shall be submitted within 5 working days following the staff's date of hire, as required by 2380.20(a). DPOC by HDKP, HSLS, on 3/25/22]. 03/08/2022 Implemented
2380.113(a)Direct Service Worker #1, date of hire 5/03/2021, had an initial physical examination completed on 5/10/2021 which is after the date of hire. Direct Service Worker #2, date of hire 3/08/2021, had an initial physical examination completed on 5/10/2021 which is after the date of hire.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.Future staff will have a completed physical and t.b. test prior to the start date. [Within 30 calendar days of receipt of the Directed Plan of Correction, staff responsible for ensuring the completion of staff physical examinations shall be trained on the requirements of staff physical examinations, as indicated in 2380.113c1-4, and timeliness requirements, as indicated in 2380.113a. DPOC by HDKP, HSLS, on 3/25/22]. 03/08/2022 Implemented
2380.21(u)Individual #1, admission date 9/17/2021, was informed and explained individual rights on 9/17/2021. The rights document did not include the following rights: 2380.21b, the facility shall educate, assist and provide the accommodation necessary for the individual to understand the individual's rights; 2380.21c, to not be reprimanded, punished or retaliated against for exercising their rights; 2380.21d, a court's written order that restricts an individual's rights shall be followed; 2380.21e, a court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; 2380.21f, an individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; 2380.21g, to designate persons to assist in decision-making and exercising rights on behalf of the individual; 2380.21h, to not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; 2380.21j, to not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment; 2380.21l, to make choices and accept risks; 2380.21m, to refuse to participate in activities and services; 2380.21n, the right to privacy of person and possessions; 2380.21o, the right of access to and security of individual's possessions; 2380.21p, the right to voice concerns about the services they receive. Individual #2, admission date 9/07/2021, was informed and explained individual rights on 9/07/2021. The rights document did not include the following rights: 2380.21b, the facility shall educate, assist and provide the accommodation necessary for the individual to understand the individual's rights; 2380.21c, to not be reprimanded, punished or retaliated against for exercising their rights; 2380.21d, a court's written order that restricts an individual's rights shall be followed; 2380.21e, a court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; 2380.21f, an individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; 2380.21g, to designate persons to assist in decision-making and exercising rights on behalf of the individual; 2380.21h, to not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; 2380.21j, to not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment; 2380.21l, to make choices and accept risks; 2380.21m, to refuse to participate in activities and services; 2380.21n, the right to privacy of person and possessions; 2380.21o, the right of access to and security of individual's possessions; 2380.21p, the right to voice concerns about the services they receive. Individual #3, admission date 12/02/2011, was informed and explained individual rights on 11/16/2021. The rights document did not include the following rights: 2380.21b, the facility shall educate, assist and provide the accommodation necessary for the individual to understand the individual's rights; 2380.21c, to not be reprimanded, punished or retaliated against for exercising their rights; 2380.21d, a court's written order that restricts an individual's rights shall be followed; 2380.21e, a court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; 2380.21f, an individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; 2380.21g, to designate persons to assist in decision-making and exercising rights on behalf of the individual; 2380.21h, to not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; 2380.21j, to not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment; 2380.21l, to make choices and accept risks; 2380.21m, to refuse to participate in activities and services; 2380.21n, the right to privacy of person and possessions; 2380.21o, the right of access to and security of individual's possessions; 2380.21p, the right to voice concerns about the services they receive.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.Updated Individual rights were reviewed with individuals and guardians. Between 3/1/22 and 3/4/22 to include all individuals. Individuals' rights were updated 3/2/22 after state inspection. 03/08/2022 Implemented
2380.36(a)Direct Service Worker #1, date of hire 5/03/2021, was not 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 to the local fire department as soon as possible after a fire is discovered.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.All staff has been trained in General fire safety and procedures. [Within 30 calendar days of receipt of the Directed Plan of Correction, Staff responsible for training will be trained in the requirement that Program Specialist and direct service workers shall be trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside of 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 to the local fire department as soon as possible after a fire is discovered, as required by 2380.36(a), prior to working alone with individuals. DPOC by HDKP, HSLS, on 3/25/22]. 03/08/2022 Implemented
2380.38(b)(2)Direct Service Worker #1, date of hire 5/03/2021, did not complete the training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations within 30 days after hire. Direct Service Worker #2, date of hire 3/08/2021, did not complete the training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations within 30 days after hire.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Staff has completed prevention, detection, and reporting suspected abuse and alleged abuse in accordance with the older adults protective service act,, the adult protective service act, and applicable protective service regulations.3/2/22-3/8/22 The child protective service law will be completed by all staff 3/11/22. [Within 30 calendar days of receipt of the Directed Plan of Correction, staff responsible for orientation training shall be trained in the requirement that all staff must be trained prior to working alone with individuals, and within 30 days after hire, in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with Older Adult Protective Services Act, the Child Protective Services Law, the Adult Protective Services Act, and applicable protective services regulations, as required by 2380.38b2. DPOC by HDKP, HSLS, on 3/25/22]. 03/08/2022 Implemented
2380.38(b)(3)Direct Service Worker #1, date of hire 5/03/2021, did not complete the training in Individual Rights within 30 days after hire. Direct Service Worker #2, date of hire 3/08/2021, did not complete the training in Individual Rights within 30 days after hire.The orientation must encompass the following areas: Individual rights.Staff has complete Individual rights through O.D.P. and received a certificate 3/2/22-3/8/22. [Within 30 calendar days of receipt of the Directed Plan of Correction, staff responsible for orientation training shall be trained in the requirement that all staff must be trained prior to working alone with individuals, and within 30 days after hire, in individual rights, as required by 2380.38b3. DPOC by HDKP, HSLS, on 3/25/22]. 03/08/2022 Implemented
2380.38(b)(4)Direct Service Worker #1, date of hire 5/03/2021, did not complete the training in Recognizing and reporting incidents within 30 days after hire. Direct Service Worker #2, date of hire 3/08/2021, did not complete the training in Recognizing and reporting incidents within 30 days after hire.The orientation must encompass the following areas: Recognizing and reporting incident.The staff has completed training for Recognizing and Reporting incidents. Between 3/2/22-3/4/22. [Within 30 calendar days of receipt of the Directed Plan of Correction, staff responsible for orientation training shall be trained in the requirement that all staff must be trained prior to working alone with individuals, and within 30 days after hire, in recognizing and reporting incidents, as required by 2380.38b4. DPOC by HDKP, HSLS, on 3/25/22]. 03/08/2022 Implemented
SIN-00157036 Renewal 06/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)At 11:40AM, the hot water temperature at bathroom sink in the bathroom near the main entrance of the facility measured 124.5 degrees Fahrenheit.Hot water temperatures in areas accessible to individuals may not exceed 120°F.On June 14, 2019, management adjusted and monitored the temperature on the hot water tank in the facility. To provide compliance and accountability, a spreadsheet has been developed on June 19, 2019, to monitor water temperatures. Water temperatures will be monitored on July 1, 2019, and management will reassess temperatures on the first of every month thereafter. Also, on June 25, 2019, management purchased a new digital thermometer to ensure compliance in the future. On June 27, 2019, supporting documentation will be submitted to the Office of Developmental Programs. [The thermometer on hot water tank was adjusted on 6/13/19 and rechecked on 6/14/19 and the temperature was 114.8 and retested on 6/17/19 reading was 115.3. At least quarterly, the CEO or designee shall audit the aforementioned tracking documentation to ensure completion and that the hot water temperatures in areas accessible to individuals does not exceed 120°F. (DPOC by AES, HSLS on 7/3/19)] 06/25/2019 Implemented
SIN-00137122 Renewal 06/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(3)Direct Service Worker #1 physical examination completed 1/3/18 did not include a signed statement that the person is free of serious communicable disease. This section was blank.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 Physical Examination Requirements As of 7/27/18, TracyJo Herman, owner of TracyJo¿s Adult Day Center, has reviewed all required staff physical documents to ensure compliance with 2380.113 C (3). TracyJo¿s Adult Day Center has now updated staff physical required documentation pertaining to (2380.113 C (3)) staff physical examination requirements. All required fields for staff physicals have been highlighted in yellow and will not be accepted for employment unless completed in full by a licensed physician, certified nurse practitioner or certified physician¿s assistant. This change will take place 7/27/18. [Documentation of audits of ISP review signatures shall be kept. (DPOC by AES,HSLS on 8/17/18)] 07/27/2018 Implemented
2380.181(d)The program specialist did not sign Individual #1's assessment completed 11/03/17. (Repeated Violation-7/12/17, et al)The program specialist shall sign and date the assessment.Assessment Review and Signature Verification As of 7/27/18, TracyJo Herman, owner of TracyJo¿s Adult Day Center, has reviewed all individual¿s records enrolled in the day program to ensure compliance with individuals¿ assessment signature sheets. All recommendations and violations have been reviewed and corrected. TracyJo¿s Adult Day Center has now incorporated Assessment Review and Signature Verification (2380.181(d)) into Quality Management Training to ensure compliance with regulations. TracyJo Herman (owner) will review assessment sign off sheets quarterly to ensure the Program Specialist and the individual has reviewed the assessment and signed off. If the individual is unable or refuses to sign the assessment, the Program Specialist will initial and document (on the signature line) that the individual is unable to sign or refused to sign. This change will take place 7/27/18. [Documentation of audits of ISP review signature shall be kept. (DPOC by AES,HSLS on 8/17/18)] 07/27/2018 Implemented
2380.186(b)The program specialist and Individual #1 did not sign the ISP review completed 5/2/18. Individual #1 did not sign the ISP review completed 11/3/17. Individual #2 did not sign the ISP reviews completed 1/3/18 and 4/2/18. The program specialist and Individual #3 did not sign the ISP review completed 4/2/18. Individual #4 did not sign the ISP reviews completed 7/6/17, 10/3/17, 1/2/18, and 4/3/18.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.ISP Review and Revision As of 7/27/18, TracyJo Herman, owner of TracyJo¿s Adult Day Center, has reviewed all individual¿s records enrolled in the day program to ensure compliance with individuals¿ ISP review signature sheets. All recommendations and violations have been reviewed and corrected. TracyJo¿s Adult Day Center has now incorporated ISP Review and Revision (2380.186(b)) into Quality Management Training to ensure compliance with regulations. TracyJo Herman (owner) will review ISP/3-month review sign off sheets quarterly to ensure the Program Specialist and the individual has reviewed the ISP/3-month review and signed. If the individual is unable or refuses to sign the ISP review and revision, the Program Specialist will initial and document (on the signature line) that the individual is unable to sign or refused to sign. This change will take place 7/27/18. [Documentation of audits of ISP review signature shall be kept. (DPOC by AES,HSLS on 8/17/18)] 07/27/2018 Implemented
SIN-00117219 Renewal 07/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #3 had a physical examination completed 1/14/16 and then again on 2/1/17. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.TracyJo's Adult Day Center did not receive physical examination from Residential Program Specialist in a timely manner. To ensure future compliance, a spreadsheet will be created by TracyJo Herman to track physical examination dates for individuals. A reminder will be sent to Residential Program Specialists 30 days in advance of due dates. A follow-up phone call will be made prior to physical examination expiration date. Staff has been trained by management on use of all spreadsheets. This change has been implemented as of 7-24-2017. [At least quarterly for 1 year, the CEO or designee shall review the aforementioned tracking system and the current individuals' physical examinations to ensure timely completion. (AS 7/28/17)] 07/24/2017 Implemented
2380.181(d)The program specialist did not sign or date the assessment dated 3/8/17 for Individual #2.The program specialist shall sign and date the assessment.Assessment for individual #2 has been signed and dated, as of 7-13-2017. Due to an oversight, Program Specialist has been retrained, as of 7-24-2017, to ensure that assessments will be signed, dated and checked for compliance. All other files have been reviewed by TracyJo Herman and are found to be in compliance. [For at least 1 year, the CEO or designee shall review, all completed assessments to ensure the program specialist signed and dated the assessments. (AS 7/28/17)] 07/24/2017 Implemented
2380.181(f)The program specialist did not provide the assessment dated 6/6/17 for Individual #1 to the plan team members prior to the ISP meeting completed 6/29/17.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).Individual #1's assessment date has been moved back two weeks to ensure compliance for ISP meeting date. In the future, assessment will be completed by Program Specialist and sent to team members no later than 5-22-2017 to ensure that team members receive assessment 30 days prior to ISP team meeting. This change has been implemented as of 7-24-2017. All client files have been reviewed by TracyJo Herman to ensure that assessments are completed 30 days in advance of all individual's ISP team meetings and sent to team members. To ensure future compliance, Program Specialist will attach confirmation emails in the client's files.[For at least 1 year, the CEO or designee shall review the correspondence documentation showing the program specialist provided all individuals' assessments to the plan team members, timely. (AS 7/28/17)] 07/24/2017 Implemented
2380.186(d)The program specialist did not provide the ISP review documentation date 10/4/16, 12/30/16, and 4/3/17 for Individual #1 to the plan team members. The program specialist did not provide the ISP review documentation date 9/2/16, 12/2/16, 3/1/17, and 6/2/17 for Individual #2 to the plan team members. The program specialist did not provide the ISP review documentation date 9/30/16, 12/30/16, and 3/31/17 for Individual #3 to the 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.Program Specialist did provide review documentation to team members. However, Program Specialist failed to document dates. For future compliance, Program Specialist will attach email confirmation to client file. This change has been implemented as of 7-24-2017. TracyJo Herman (owner) has provided Program Specialist training on specific emailing process and reviewed all files to ensure compliance of all individuals.[For at least 1 year, the CEO or designee shall review the correspondence documentation showing the program specialist provided all individuals' ISP review documentation to the plan team members, as required, timely. (AS 7/28/17)] 07/24/2017 Implemented
SIN-00106818 Unannounced Monitoring 01/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.51There are two sets of steps present at the front exit of the facility which are not accessible for mobility devices. The facility serves five individuals who have mobility needs requiring the need to utilize mobility devices. One individual requires the use of a walker, three individuals require the use of wheelchairs and one individual who is visually impaired and requires the use of both a wheelchair and walker. A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual's needs.In reference to the inspection on 1/11/2017 our facility was informed that we were to install temporary handrails on both sets of steps, these were installed and photos were sent to the inspector on1/24/2017. Since that time we were informed that we were to install a ramp on the front entrance, management contacted progressive Mobility on1/25/2017. A representative is scheduled to come on 1/30/2017 to take measurements and give estimate for ramp. His name is Jeff There number is 724-705-9012, they are out of Washington Pa. Management will keep you informed of time frame. [A ramp was installed May 26, 2107 making the front exit of the home accessible to the individuals in the facility. Within 30 days of receipt of the plan of correction, the CEO of the facility shall develop and implement policy and procedures to ensure the exits of the home are unobstructed and the individuals have safe accessibility for entrance and exit from the facility. (AS 6/13/17)] 01/30/2017 Implemented
SIN-00098766 Renewal 07/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.64(a)The four wooden steps leading from the front porch of the home did not have a handrail.Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.[Hand rails were installed on 1/20/17. At least monthly, a designated staff person shall complete an on site check to ensure the handrails on each ramp, interior stairway and outside steps is in place and well secured. (AS 3/17/17) 09/18/2016 Implemented
2380.113(a)Program Specialist #1's most recent physical examinations were completed on 12/11/13 and 1/11/16.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.  09/18/2016 Implemented
SIN-00079522 Renewal 07/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1, date of admission 3/19/15, and Individual #2, date of admission 4/9/15, were not instructed 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. 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.Program Specialist will reinstruct clients #1and #2 in general firesafety evacuation procedures and responsibilities during fire drills. (Documentation was lost in a fire on 4/19/2015). Will send verification to representative by 7/31/2015. Program Specialist will be responsible for future compliance. [Program specialist will immediately review all individuals' records for completed fire safety training and will address as needed and will develop a tracking system to ensure timeliness of initial fire safety training as well as annual fire safety training. (AS 10/1/15)] 07/20/2015 Implemented
2380.173(1)(v)The records for Individual #1 and Individual #2 did not include a current, dated photograph.Each individual's record must include the following information: Personal information including: A current, dated photograph.Program Specialist will retake photo of clients #1 and #2 and put dated copy in client's file. ( photos were lost in a fire on 4/19/2015). Will send copy to representative by 7/31/2015. Program Specialist will be responsible for future compliance.[Program Specialist will immediately review all individual records for required personal information including a current dated photo and will immediately address as needed. (AS 10/1/15)] 07/20/2015 Implemented
2380.181(a)Individual #1, date of admisison 3/19/15, and Individual #2, date of admission 4/9/15, did not have an initial assessment.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.Program Specialist will complete an initial assessment on clients #1 and #2,and will also be responsible for completing annual assessments in the future. (assessments were lost in a fire on 4/19/2015). Will forward supporting documentation to representative by 7/31/2015. [Program specialist will immediately review all individuals' records for completed assessments to include all required information as specified 181(e)1-14 and will address as needed and will develop a tracking system to ensure timeliness of initial assessments as well as annual assessments. (AS 10/1/15)] 07/20/2015 Implemented
SIN-00065713 Renewal 07/07/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Indiviuals #1, #2, #3 and #4 were not instructed in general fire safety, evacuation procedures, responsiblities during fire drills, the designated meeting place outside the building and smoking safety procedures.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 were instructed in fire safety according to the fire safety log but there was no verification in client file. Have developed a fire safety training sign off sheet to put in client file. Director will insure future compliance Date completed 07-11-2014. 07/26/2014 Implemented
2380.160(b)According to staff interviews and a review of record documentation, Individual #2 and Individual #3 utilize waist belts which are secured over his/her lap while attending the program. There are no physician's orders for either individual that specified that the purpose of the waist belts were for body positioning. There are no physician's orders for either individual that specified the amount of time the waist belts could be worn. The use of a mechanical restraint is prohibited except for the use of helmets, mitts and muffs to prevent self-injury on an interim basis but only for the first 3 months after admission.After inspection I found documentation in client's file that pertains to this violation,will send to licensing representative for verification. Have prepared a sign off sheet to insure lap belts are monitored every 60 minutes while client is in facility. Director will insure compliance in the future Date completed 07-10-2014 07/26/2014 Implemented
2380.173(7)The records for Individuals #1, #2, and #3 do not contain current copies of the ISPs.Each individual's record must include the following information:  A copy of the current ISP.Have made copies of all ISP's and put them in all client files.Have put notes in all client files that states that ISP's are to be updated at the end of fiscal year. Director will insure future compliance. Date Completed 07-08-2014 07/26/2014 Implemented
2380.181(e)(11)Individual #4's assessment completed on 9/12/13 did not include a psychological evaluation. According to Individual #4's ISP last updated 6/25/14, s/he has a behavioral support plan which addresses compulsive incidents in public. The assessment must include the following information: Psychological evaluations, if applicable.Have obtained copy of individual#4's psychological evaluation and included it in client folder.This was due to an over site. Director will insure future compliance. Date completed 07-11-2014 [Per conversation with provider on 9/4/14, all individual's records will be audited to ensure that they contain a copy of a psychological evaluation if applicable. (CHG 9/8/14)] 07/26/2014 Implemented
SIN-00278693 Renewal 11/25/2025 Compliant - Finalized
SIN-00237299 Renewal 01/11/2024 Compliant - Finalized