Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286606 Renewal 04/08/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)Poisons in original bottles. Kitchen had a clear bottle with a clear liquid. Program room had a pink bottle with a clear liquid.Poisonous materials shall be stored in their original, labeled containers.The spray bottles with clear liquids contained water for spraying plants and were dumped and thrown in the trash immediately by Program Specialist/Site Supervisor. (Photo-Attachment #1) 04/08/2026 Implemented
2380.58(a)Good repair. Women's bathroom handicap seat was very loose to the touch. It was not sturdy and needs to be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair.A work order to have seat replaced was completed by Program Specialist/Site Supervisor on 4/8/26 (Attachment #4). Seat was replaced by Avenues maintenance on 5/4/26 (Photo-Attachment #5). 05/04/2026 Implemented
2380.58(b)Dryer had significant lint which is a fire hazard.Floors, walls, ceilings and other surfaces shall be free of hazards.Program Specialist/Site Supervisor cleaned lint trap at time of inspection on 4/8/26 (Photo-Attachment #6). 04/08/2026 Implemented
2380.111(c)(10)Individual # 3 physical dated 2/13/26 did not list medical information pertinent to diagnosis and treatment in case of an emergency. That are of the physical was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist contacted Individual #3's residential provider to have her physician provide the information pertinent to diagnosis and treatment in case of an emergency. Information was received from Individual #3's PCP on 4/16/26 and was filed with her current physical in her chart (Attachment #8). 04/16/2026 Implemented
2380.113(c)(2)Staff shall have a physical 12 months prior to employment, which includes the negative TB results. Staff#1 DOH was 7/8/25 and the TB results were dated 7/9/25. This exceeds the time frame required by the regulation.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.Though staff #1 did not work directly with individuals until 7/10/25, she did begin orientation with the Agency trainer on 7/8/25, after her physical was completed but before her TB test was read on 7/9/25. The regulation and citation issues were conveyed by Program Manager to Avenues Human Resources Manager who schedules all staff physicals and start dates for new hires. 05/05/2026 Implemented
2380.171(b)(3)The emergency record shall have the name, address and telephone number of the person able to give consent for emergency treatment. The name on individual #3 record was crossed out with black ink and no one new was identified on this document.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.Program Specialist/Site Supervisor contacted Individual #3's residential provider to get the name of the new contact able to give consent for emergency medical treatment and added it to Individual #3's file (Attachment #11). 04/10/2026 Implemented
2380.173(1)(v)The individual record shall include a current photo of the individual. (Current photo is defined by the RCG is a photo taken annually or when a person's appearance changed drastically, such as significant weight loss, hair loss or hair color, ect) Individual #1 was re admitted to the program on 3/21/25, and the photo in his file was dated 2024.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.An updated photograph of Individual #1 taken on 1/12/26 was added to his chart and his electronic record on 4/8/26 (Attachment #12). 04/08/2026 Implemented
2380.181(e)(13)(iii)Individual #1 annual assessment dated 1/5/26 did not list the progress and growth in personal adjustment. The assessment reflects that this was the individual's initial assessment, however the initial assessment was completed on 5/19/25.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.An addendum to the annual skills assessment addressing his current level of progress and growth over the last 365 days was completed by the Program Specialist for Individual #1 and added to his file (Attachment #13). 05/04/2026 Implemented
2380.21(l)Individual's shall be involved in the decision making about desired community activities quarterly. There was no documentation in Individual #2 record to reflect that this conversation occurred at the appropriate time frames as required by the regulation.An individual has the right to make choices and accept risks.Discussions regarding community activities were completed at Individual #2's quarterly meetings on 8/5/25 and 11/6/25. No discussion took place at her meeting on 2/13/26 due to her being in a nursing home with possible discharge from program (Attachment #14). Quarterly discussions will take place for all individuals going forward. 05/04/2026 Implemented
SIN-00268573 Renewal 07/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1's physical examination dated 3/3/25 did not include vision and hearing screenings. Individual #1's physical examination indicated that the individual is followed by an optometrist and Ear Nose and Throat Specialist. There was no documentation from either of these specialists.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #1's physical was completed on 3/3/25. She had vision screenings completed by Dr. Akirta Sran on 3/27/24 and 7/21/25 (Attachment #1) and a hearing exam completed by Pottsville ENT on 12/30/24 (Attachment #2). Copies of the exams were received by Avenues on 7/21/25 and put in Individuals #1's file. 07/21/2025 Implemented
2380.111(c)(7)Individual #1's annual physical exam dated 3/3/25 did not include an assessment of the individual's medication regimen. This section of the physical exam was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Program Specialist, Jacquie Kurtek, contacted Individual #1's primary care physician on 7/23/25 to request an update indicating that Individual #1 does note take any medications on a regular basis (Attachment #4). When information is received by the doctor's office, it will be filed in Individual #1's file. 07/28/2025 Implemented
2380.111(c)(10)Individual #2's annual physical exam dated 5/22/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical exam was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Please note, it was actually Individual #3 whose physical did not contain information pertinent to diagnosis and treatment in case of emergency, not Individual #2. Program Specialist, Jacquie Kurtek, reached out to Individual #2's primary care physican to request that required information be added to his physical on 7/23/25 (Attachment #5). When the information is FAXed to Avenues by the doctor's office, it will be added to his file. 07/28/2025 Implemented
2380.21(l)ODP Announcement 24-061 outlines the Federal requirements for individuals to be involved in decision-making about desired community activities, the regulatory requirements in Chapters 2380, 2390 and 6100, and what is required to comply with the regulatory requirements. Providers who deliver Community Participation Support and/or Day Habilitation in Chapter 2380 or Chapter 2390 programs must document conversations with individuals, beginning July 1, 2024, relating to their preferred community participation and activities at least quarterly. There was no documentation in the individual records of Individuals #1, and #3 those conversations occurred with each of the individuals since the implementation of ODP Announcement 24-061. Individual #1 began attending the program on 3/3/25 and should have had at least one documented conversation relating to the individual's preferred community participation activities. There was no documentation in Individual #1's record that this conversation occurred.An individual has the right to make choices and accept risks.While conversations regarding CPS activities and choice took place quarterly, desired locations of community activities were not documented. Program Specialist had conversations with Individual #1 on 7/18/25 and with Individuals #2 and #3 on 7/23/25 and documented their right to make decisions regarding community activities and locations of desired activities (Attachment #6). 07/28/2025 Implemented
SIN-00247826 Renewal 07/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #1 had a physical examination on11/18/20 and the next physical examination occurred on 2/14/23.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.To correct this area of non-compliance, Avenues' biennial physical exams are now scheduled with testing agency for existing employees two weeks prior to due date to ensure that physicals are completed and returned to Human Resources representative within the required time frame. Human Resources representative will be responsible for the implementation and continued compliance of the plan. All physical testing sites were contacted on 11/16/23 to make them aware that staff physicals with Mantoux tests would be scheduled two weeks prior to the due date going forward. Policy/procedure was updated by Human Resources Representative on 12/11/23 (Attachment #1). 08/23/2024 Implemented
SIN-00225329 Renewal 07/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #1 date of hire was 9/15/2022 and the only record of a criminal history check was documented on 7/11/2023. The criminal history check should be within 5 working days of initial 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.Avenues' Human Resources Manager created a new hire checklist to make sure that all pre-employment requirements and checks are completed within the required time frames. Completed documents will be uploaded into iSolved (Avenues' timekeeping/payroll system) and a hard copy kept in the employee's paper file in the HR office. 08/03/2023 Implemented
2380.111(c)(3)Individual #1 had a physical dated 6/15/23. The physical documents the individual's immunization records. This individual had a TDAP on 12/12/12. The most recent TDAP was on 6/15/23. This exceeds the US Public Health Service Center for Disease Control and Prevention recommendation for the TDAP to occur 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.Individual #1's previous physical (2022) was completed in June, however, her TDAP was not due until December of 2022. The TDAP immunization was not administered in December, rather it was completed at her next physical on 6/15/23, causing it to be overdue. Program Specialist created a paperwork due date checklist to track compliance with all required paperwork, including physical, TDAP, and TB testing (Attachment #2). 08/03/2023 Implemented
SIN-00207823 Renewal 07/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(13)(vi)Individual #1's assessment dated 7/7/22 did not address their progress over the last 365 calendar days and current level in the area of community integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.An addendum was added to Individual #1's 7/7/22 assessment to address the current level of community integration and progress over the last 365 days. (Attachment #1) 07/25/2022 Implemented
SIN-00171756 Renewal 02/18/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)This section was blank on Individual #1's (DOB: 5/25/1991) physical exam dated 10/10/2019 and Individual #2's (DOB: 10/21/1957) physical exam dated 5/17/2019.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #1 and Individual #2's physician's were contacted and the information pertinent to diagnosis and treatment in case of an emergency was added to both physicals by the doctor's office (Attachments #2 and #3). In the future, program specialists will use the physical exam checklist when receiving physicals for program participants in order to ensure that all sections of the physical are completed (Attachment #4 A & B) . If there are blank sections, they will contact the family, residential provider, and/or the doctor to have all sections filled in. 03/04/2020 Implemented
2380.173(1)(v)There was no dated photograph in Individual #2's record.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.A photograph of Individual #2 was taken and added to her file the day after licensing (2/19/2020, Attachment #1). In the future, photographs will be taken the first day a new individual begins attending the program. 02/19/2020 Implemented
SIN-00058312 Renewal 12/11/2013 Compliant - Finalized