Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242219 Renewal 03/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61At 12:53PM, the floor in front of the toilet in the men's restroom near the front of the building has several areas of disrepair posing a tripping and falling hazard. The areas of disrepair include a jagged edged area approximately three inches by eight inches where the underlay of the floor is exposed and protruding, multiple cracks spanning over at least eight of the floor tiles, and a cracked area approximately two inches by two inches that is recessed. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The Executive Director contacted Don Huey Custom Building and Remodeling, Inc. on Wednesday, March 27, 2024. On Thursday, March 28, 2024, Don Huey thoroughly assessed the restroom area identified as hazardous during the Wednesday, March 27, 2024, licensing inspection. An estimate to remove the existing floor tile, remove the rubber baseboard, repair the wood section of the sub-floor, install a commercial LVT tile, remove and reinstall the toilets and fixtures, repair the drywall, and prime and paint from Don Huey Custom Building and Remodeling, Inc. was received and forwarded to all ICW Board members for approval on Thursday, March 28, 2024. The estimate was approved on Monday, April 1, 2024, by a Board majority. Don Huey Custom Building and Remodeling, Inc. was informed on Monday, April 1, 2024, of the approval. Work to repair the restroom began on Wednesday, April 10, 2024. (A construction in progress picture was emailed to the ODP Western Region Licensing Supervisor on Friday, April 12, 2024.) Also, A memo regarding Hazards and a newly revised monthly safety inspection checklist was issued on Thursday, April 4, 2024. The Executive Director and Safety Director discussed the newly revised monthly safety inspection checklist on Thursday, April 4, 2024; specifically, the addition of a Visible Hazards Section. 04/04/2024 Implemented
SIN-00204518 Renewal 05/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Individual #1 was informed and explained their individual rights on 8/10/20 and then again 2/14/22.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.A memo was sent and given to the Program Specialists in charge of maintaining the individual files and maintaining compliance with the regulations; specifically addressing the need to have individual rights explained to the individuals upon admission to the facility, upon return from a leave of absence and annually thereafter. 05/05/2022 Implemented
SIN-00088514 Renewal 01/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(b)(2)Program Specialist #3's job description did not include responsibility to provide assessment to plan team members.The program specialist shall be responsible for the following: Providing the assessment as required under § 2380.181(f) (relating to assessment). John Waddell's (Program Specialist) job description includes the responsibility of completing assessments (number 2, section 1). John have been given a copy of the job description, and signed and dated the last page.[CEO will ensure all current and new program specialist are informed of the job duties of the program specialist. (AS 3/4/16)] *Supporting Documentation emailed to jroser@pa.gov 02/08/2016 Implemented
2390.87Direct Service Worker #1, date of hire 7/21/2015, and Direct Service Worker #2, date of hire 7/20/2015, were not instructed in general fire safety upon initial employment.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.The Safety Coordinator (Peggy Gryczuk) was sent a memo reminding her to provide fire safety training to all new employees, on the first day of their employment with ICW. She will begin doing this immediately. *Supporting documentation emailed to jroser@pa.gov[Direct Service Workers #1 and #2 were trained in fire safety on 1/11/16. Safety Coordinator will complete fire safety instruction. Documentation of instruction shall be kept and reviewed by assistant director to ensure timely completion of fire safely training. (AS 4/5/16)] 02/08/2016 Implemented
2390.111(c)The facility did not keep notifications of admission for Individual #6, date of admission 10/07/2015, and Individual #7, date of admission 2/09/2015.The facility shall keep dates of interviews and notifications of admission and denial of admission on file for 3 years.A checklist was developed and given to the Program Specialists for them to use to ensure that all forms (including the ISP invite letter, the admission letter, and all ISP review forms) are present in the individuals' files. Memos were sent to the Program Specialists providing them with the checklist and instructing them to use the checklist to not only ensure that the forms are completed and placed in the files initially; but to also review their files using the checklist periodically to ensure all files are in compliance. The Program Specialists were also instructed that the ISP review form must still be completed, even if an individual is on a medical leave of absence. Also, all forms and paperwork in the individual files will now be placed in the files in the same order, ensuring that the files will be more organized and easier to check. *Supporting documentation emailed to jroser@pa.gov [Program Specialist will review records and complete aforementioned checklist at least quarterly to ensure all required information is completed and in the record. CEO or Assistant Director will review aforementioned checklists at least twice a year to ensure all required documentation in completed and in the record for all individuals. Documentation of all reviews shall be kept. (AS 3/4/16)] 02/08/2016 Implemented
2390.124(8)(ii)Individual #1's record did not include a copy of invitation to the annual update meeting that occured on 12/21/2015.Each client's record must include the following information: A copy of the invitation to: The annual update meeting.A checklist was developed and given to the Program Specialists for them to use to ensure that all forms (including the ISP invite letter, the admission letter, and all ISP review forms) are present in the individuals' files. Memos were sent to the Program Specialists providing them with the checklist and instructing them to use the checklist to not only ensure that the forms are completed and placed in the files initially; but to also review their files using the checklist periodically to ensure all files are in compliance. The Program Specialists were also instructed that the ISP review form must still be completed, even if an individual is on a medical leave of absence. Also, all forms and paperwork in the individual files will now be placed in the files in the same order, ensuring that the files will be more organized and easier to check. *Supporting documentation emailed to jroser@pa.gov [Program Specialist will review records and complete aforementioned checklist at least quarterly to ensure all required information is completed and in the record. CEO or Assistant Director will review aforementioned checklists at least twice a year to ensure all required documentation in completed and in the record for all individuals. Documentation of all reviews shall be kept. (AS 3/4/16)] 02/08/2016 Implemented
2390.151(a)Individual #5, date of admission 8/26/2015, did not have an initial assessment.Each client 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.The Program Specialists were sent a memo instructing them to only use the proper (and updated) annual assessment forms. Cassie Eiselman (Assistant Director) is responsible in letting the Program Specialists know when ISPs are scheduled, and ensuring that the Program Specialists complete the annual assessment and complete it using the proper form. Also included in the memo were reminders to never use white out and to always use newer (and up to date) versions of forms, as was suggested by the inspectors. *Supporting documentation emailed to jroser@pa.gov [Individual #5's assessment was completed 1/11/16. Individual #5 no longer attends vocational facility. The Program specialists will complete assessments within required time frames. Assistant Director will review the next 5 new admissions to ensure initial assessments are completed timely. Documentation of reviews shall be kept. (AS 4/5/16)] 02/08/2016 Implemented
2390.151(f)The program specialist did not provide the assessment to all team members for Individual #1's assessment dated 11/18/15, Individual #2's assessment dated 9/11/15, Individual #3's assessment dated 12/4/15, Individual #4's assessment dated 4/20/2015, Individual #6's assessment dated 11/18/15, and Individual #7's assessment dated 1/9/15.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).The assessment form has been changed to include a line for a date which indicates on what date the copy of the annual assessment was sent to the Supports Coordinator, individual, family/guardian, residential program, community and habilitation program or any other program with which the individual may be involved. The Program Specialists will be instructed to use these new forms for the annual assessment beginning immediately.*Supporting documentation emailed to jroser@pa.gov [Program Specialist will review all individuals' to ensure the entire team is provided assessments for all individual. CEO or Assistant Director will review 25% of the aforementioned assessment forms at least quarterly to ensure the entire team is provided assessments for all individual. Documentation of all reviews shall be kept. (AS 3/4/16)] 02/08/2016 Implemented
2390.153(5)Individual #1, prescribed Celexa to treat ADHD, did not have a protocol to address the social, emotional, and environmental needs. Individual #2, prescribed Zyprexa to treat Schizophrenia, did not have a protocol to address the social, emotional, and environmental needs. Individual #3, prescribed Fluoxetine to treat depression, did not have a protocol to address the social, emotional, and environmental needs. Individual #4, prescribed Ziprasidone to treat Psychosis, did not have a protocol to address the social, emotional, and environmental needs. Individual #5, prescribed Abilify to treat Psychosis, did not have a protocol to address the social, emotional, and environmental needs.A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Cassie Eiselman (Assistant Director) will be the person responsible for writing the Social/Emotional/Environmental plan for all individuals who attend ICW who are currently taking psychotropic medications. SEE plans have been written for the two individuals found not in compliance with this regulation; and Cassie is in the process of writing plans for the other individuals attending ICW who need these plans. The original plans will be placed in the individuals' files, with a copy being sent to the individuals' Supports Coordinator. Cassie will check the ISP's of individuals starting ICW to determine if they are taking psychotropic medications and will write the SEE plan for these individuals when they start.[Individual #5's SEE Plan was completed on 1/22/16. Individual #1's SEE Plan was completed on 2/12/16. Individual #2's SEE Plan was completed on 1/15/16. Individual #4 SEE plan was completed on 1/15/16. Individual #5's SEE Plan was completed on 1/15/16. Immediately, Assistant Director will review all individuals' records to ensure SEE Plan are completed for all individual who medication has been prescribed to treat symptoms of a diagnosed psychiatric illness and complete SEE Plans as needed. (AS 4/5/16)] 02/08/2016 Implemented
2390.156(a)Program specialist did not complete a 3 month review for the period of 2/2015 through 4/2015 for Individual #4. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.A checklist was developed and given to the Program Specialists for them to use to ensure that all forms (including the ISP invite letter, the admission letter, and all ISP review forms) are present in the individuals' files. Memos were sent to the Program Specialists providing them with the checklist and instructing them to use the checklist to not only ensure that the forms are completed and placed in the files initially; but to also review their files using the checklist periodically to ensure all files are in compliance. The Program Specialists were also instructed that the ISP review form must still be completed, even if an individual is on a medical leave of absence. Also, all forms and paperwork in the individual files will now be placed in the files in the same order, ensuring that the files will be more organized and easier to check. *Supporting documentation emailed to jroser@pa.gov [Immediately, the program specialist will review all records to ensure all 3 months reviews are completed and will document on the aforementioned checklist. At least quarterly, the program specialist will review records and complete aforementioned checklist at least quarterly to ensure all required information including 3 month reviews is completed and in the record. CEO or Assistant Director will review aforementioned checklists at least twice a year to ensure all required documentation including 3 month reviews is completed and in the record for all individuals. Documentation of all reviews shall be kept. (AS 3/4/16)] 02/08/2016 Implemented
2390.156(d)Individual #1's 3 month IPS review documentation dated 2/27/15, 5/29/15, 8/31/15, and 11/30/15 were not sent to all plan team members. Individual #2's 3 month IPS review documentation dated 12/22/14, 3/31/15, 6/30/15, and 9/30/15 were 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.The wording on the 3 month ISP Review Form was changed to specify that other agencies and providers (residential, home and community habilitation, legal guardians, etc...) were sent a copy of the Review Form. Wording was also included (Accept/Decline Form) to indicate whether the copy was accepted, or if a letter of declination was in the file declining the review. The Program Specialists will be instructed to begin using these forms and to ensure that the "other" line is filled out, indicating that the review was sent to the providers requesting the form. *Supporting documentation emailed to jroser@pa.gov [Individual #1's 3 month IPS review documentation dated 2/27/15, 5/29/15, 8/31/15, and 11/30/15 were sent to all plan team members. Individual #2's 3 month IPS review documentation dated 12/22/14, 3/31/15, 6/30/15, and 9/30/15 was sent to all plan team members. Program Specialist will review all individuals' to ensure the entire team is provided 3 month ISP reviews for all individual as required. CEO or Assistant Director will review 25% of the aforementioned 3 month ISP review forms at least quarterly to ensure the entire team is provided 3 month ISP reviews for all individuals. Documentation of all reviews shall be kept. (AS 4/5/16)] 02/08/2016 Implemented
2390.156(e)The program specialist did not provide notice to all plan team member of the option to decline the ISP review documentation for Individual #1, Individual #2, and Individual #3. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Cassie Eiselman (Assistant Director) sent out letters of declination to all other agencies and providers who are providing services to the individuals attending ICW. These letters have all been returned to ICW and have been placed in the individuals' files. Cassie Eiselman will be responsible for sending out the letter of declination to any new provider who begins working with any individual attending ICW. Supporting documentation emailed to jroser@pa.gov [Program Specialist notified team members for Individual #1 on 1/18/16 of the option to decline the ISP review documentation. Program Specialist notified team members for Individual #2 on 2/3/16 of the option to decline the ISP review documentation. Program Specialist notified team members for Individual #3 on 1/15/16 of the option to decline the ISP review documentation. Immediately, the program specialist will review all individuals' records to ensure all team members are given the option to decline the ISP review documentation and will notify team members as needed. Documentation of reviews shall be kept and reviewed by the CEO or designated management staff to ensure completion and all team members for all individuals are given the option to decline ISP review documentation. (AS 4/5/16)] 02/08/2016 Implemented
SIN-00066234 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(c)(1)Staff person #1, the program specialist, does not meet the educational qualifications of the position.A program specialist shall meet one of the following groups of qualifications: Possess a master's degree or above from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field. Possess a bachelor's degree from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field; and 1 year experience working directly with disabled persons.Jo Ann Hawk, Executive Director, reviewed personnel files for required copies of a transcript or diploma for the Executive Director and Program Specialists positions. ICW will obtain a copy of the Program Specialist¿s diploma and will place them in personnel files. A memo requesting these documents was sent out to staff on January 13, 2015. JoAnn Hawk, Executive Director will develop a checklist that will be used by the Administrative Assistant and/or Fiscal Director to review personnel files annually. A memo with an attached copy of the annual personnel file review checklist was sent out to the Administrative Assistant and Fiscal Director on January 13, 2015. Jo Ann Hawk will review checklists annually. [Transcript obtained that meets the qualifications of the position for Staff person #1. A copy of the transcript will be placed in the staff persons record. (CHG 1/16/15)] 01/18/2015 Implemented
2390.82(a)The emergency evacuation procedures do not list client responsibilities or the means of transportation to be used in an emergency.Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.Peggy Gryczuk, Safety Chairperson, made the following correction to number 5 of current emergency evacuation plan¿ staff will escort trainees across the street. Peggy Gryczuk removed copies of the obsolete Emergency Evacuation Plan and replaced them with the corrected Emergency Evacuation Plan at every evacuation diagram, employee handbook, and in the safety binder on 01/13/15. A memo with an attached copy of the corrected emergency evacuation plan was sent out to all staff on January 13, 2015. 01/18/2015 Implemented
2390.83(c)-2There are no written procedures for fire safety monitoring in the event the alarm is inoperative.There shall be a written procedure for fire safety monitoring in the event that the fire alarm is inoperative.Peggy Gryczuk, Safety Chairperson, made the following correction to number 2 of current Inoperative Fire Alarm Procedure ¿ within 24 hours, and the repairs will be completed within 48 hours after the reported problem. Peggy Gryczuk removed copies of the obsolete Inoperative Fire Alarm Procedure and replaced them with the corrected Inoperative Fire Alarm Procedure at every evacuation diagram and in the safety binder on January 13, 2015. A memo with an attached copy of the corrected Inoperative Fire Alarm Procedure was sent out to all staff on January 13, 2015. 01/18/2015 Implemented
2390.124(8)(i)Individual #1's record did not contain a copy of the invitation to the initial ISP meeting held on 4/17/14.Each client's record must include the following information: A copy of the invitation to: The initial ISP meeting.Cassie Eiselman, Assistant Director, will write a memo to both of the program specialists to be certain that the invite to the ISP meeting is received from the individual's s.c. If it is not, Cassie Eiselman will contact the s.c. or their supervisor to make certain that a copy of the invite is in the file. If ICW is the plan lead for the ISP for the individual, Cassie Eiselman will make sure that the individual receives an invitation to the ISP and that a copy of the invitation is place in the individual's file. This memo will be given to the program specialists on 01/13/15. Cassie Eiselman will do periodic checks of all of the individuals' files to ensure that the invite letters are there. 01/18/2015 Implemented
2390.124(9)(ii)Individual #2's record did not contain a copy of the ISP signature sheet from the annual ISP update meeting held on 11/21/14.Each client's record must include the following information: A copy of the signature sheet for: The annual update meeting.A memo will given to both of the program specialists reminding them of the need to have the current ISP signature sheet in each individuals' file. If they have difficulty obtaining this, Cassie Eiselman will address the issue with the s.c. supervisor. The program specialist will be given this memo on 01/13/15. Cassie Eiselman will periodically check the individual files to ensure that the current ISP signature sheet for each individual is in their file. 01/18/2015 Implemented
2390.151(e)(10)The records for Individuals # 1, #3, # 4, #5 and #6 did not contain a Lifetime Medical History.The assessment must include the following information: A lifetime medical history.Cassie Eiselman, Assistant Director, will develop a form for the program specialists to use in writing a lifetime medical history for each individual in completing their yearly assessments. The information on the lifetime medical history will be obtained from the individual's ISP or from researching the information with the assistance of the individuals' family, MH provider, residential providers, etc.... 01/18/2015 Implemented
2390.151(f)Individual #7's assessment, completed on 6/9/14, was given to the team on the day of the ISP meeting on 7/8/14.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).Cassie Eiselman, Assistant Director, will write a memo to both program specialists regarding the importance of getting a copy of the yearly assessment to the individual's s.c. 30 days prior to the ISP meeting date. This memo will be given to both program specialists on 01/13/15. Cassie Eiselman will review and sign all assessments to ensure that this is being done consistently. 01/18/2015 Implemented
2390.156(d)Individual #4's quarterly reviews dated 5/30/14 and 11/26/14 were not sent to the SC. 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.The reviews had been sent to the s.c., but the program specialist left the "date sent" square on the reviews blank. Cassie Eiselman, Assistant Director, will write a memo to both program specialists, reminding them of the importance of not leaving any dates blank on any forms. This memo will be given to the program specialists on 01/13/15. Cassie Eiselman will periodically spot check the files of the individuals who attend ICW to ensure that the program specialists are being diligent in filling in the dates on all forms. 01/18/2015 Implemented
SIN-00051726 Renewal 11/25/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)The facility conducted a fire drill on March 28, 2013. The previous fire drill was conducted on 12-19-12.(a) A fire drill shall be held at least every 90 calendar days.The Safety Director will submit a fire drill schedule to the Executive Director annually. Fire drills will be scheduled every 80 days with two alternative days that fall within the 90 day regulation period beginning January 1, 2014. The fire drill schedule has been completed for 2014 by the Safety Director and has been submitted to the Executive Director. This procedure will occur by December 15th annually and will be filed in the Safety Binder. 12/11/2013 Implemented
2390.111(b)Individual #1 had a pre-admission interview on September 23, 2013. A letter of admission sent to the participant was not dated. Therefore it cannot be determined if it was within 30 calendar days following the interview. Individual #2 had a pre-admission interview on 2-5-13. A letter of admission sent to the participant was not dated. Therefore it cannot be determined if it was within 30 calendar days following the interview. (b) Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services.The Program Managers have been instructed via memo by the Assistant Director that all dates in the files must be filled in, with no dates being left blank, beginning immediately. The Assistant Director will check files periodically to ensure that no dates are left blank. 12/11/2013 Implemented
2390.124(5)The following individuals did not have a physical examination in their record: #1, #2, #3, #4, #5, and #6.Each client's record must include the following information: (5) Physical examinations.The Assistant Director has e-mailed requests to the Supports Coordinators and two school district personnel requesting a copy of the missing physical exams. Three have been received to date, and the other Supports Coordinator and school district personnel have offered assurances that copies will be sent as soon as possible. Also, ICW has initiated a new policy madating that no one may start working at ICW, unless ICW has a current physical exam on file for the individual. This eligibility requirement has been written in the Workers Manual; and it will be reviewed with the individual and their family in the pre-admission interview. [All individual's records will be audited to ensure that they contain a physical. (CHG 12/16/13)] 12/11/2013 Implemented
2390.151(e)(10)The following individuals did not have a lifetime medical history in the assessment or documentation it was requested: #1, #2, #5, and #8.(e) The assessment must include the following information: (10) A lifetime medical history.The Assistant Director has e-mailed requests to the Supports Coordinators for a copy of the lifetime medical history. The Program Managers have been informed, via memo, that each assessment requires a lifetime medical history or documentation of the request for the lifetime medical history. The Assistant Director will check all files periodically to make certain that each file contains a lifetime medical history or a request for one. 12/11/2013 Implemented
2390.157Plan team members did not receive a copy of individual #8's ISP dated 7-22-13 within 30 calendar days. Plan team members did not receive a copy of individual #9's ISP dated 8-9-13 within 30 calendar days. A copy of the ISP, ISP annual update and ISP revision, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, ISP annual update and ISP revision meetings.The Assistant Director has developed a form, similar to the one used by the county office, for use when writing ISP's and holding ISP meetings for plan members to indicate that they received a copy of the information within thirty days. The Program Managers have been instructed to begin using this form immediately in the ISP meetings. 12/11/2013 Implemented
SIN-00263336 Renewal 03/26/2025 Compliant - Finalized
SIN-00223146 Renewal 04/20/2023 Compliant - Finalized
SIN-00187588 Renewal 05/17/2021 Compliant - Finalized
SIN-00167330 Renewal 12/20/2019 Compliant - Finalized
SIN-00148193 Renewal 01/08/2019 Compliant - Finalized
SIN-00128431 Renewal 01/30/2018 Compliant - Finalized
SIN-00107952 Renewal 02/03/2017 Compliant - Finalized