Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238553 Renewal 02/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.57The Exterior light outside of Room # 2 egress door did not work during the walk through.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.The Director is responsible for ensuring compliance with this regulation. The Director was re-trained in the requirements of regulation 2380.57. (Attachment # 1 -Training sheet & Attachment # 2 - Memo) A motion light-detector was installed by the SUNCOM maintenance man on 02/27/2024. This will ensure proper lighting outside the room #2 egress door. (Attachment # 3 ¿ Photo). 02/27/2024 Implemented
2380.58(a)The sink/faucet closest to the bathroom stall in the women's bathroom located off of program room #1 did not have running water when turned on. The right sink in the men's bathroom handle fell off during the inspection.Floors, walls, ceilings and other surfaces shall be in good repair.The Director is responsible for ensuring the floors, wall, ceilings and other surfaces are in good repair per regulation 2380.58(a) Surfaces. Staff were trained in the requirements of regulation 2380.58(a). (Attachment # 4 -Training sheet & Attachment # 5 - Memo) The Direct Service Workers are responsible for reporting when floors, walls, ceilings, and other surfaces are not in good repair to the Program Specialist. The Program Specialist is responsible for reporting when floors, walls, ceilings, and other surfaces are not in good repair to the Director. The Director is responsible for ensuring that the necessary repairs are made so that all surfaces are in good repair. The sink/faucet closest to the bathroom stall in the womens bathroom located off program room #1 did not have running water when turned on. On 02/27/2024, by removing, straightening, and reattaching the connections under the sink in the womans restroom, the SUNCOM maintenance man was able to stop the sink from leaking and the turn the water back on. It is now in good repair. (Attachment # 6 Photo). The right sinks handle in the men's bathroom located off program room #1 fell off during inspection. On 02/27/2024, by replacing and tightening a screw in handle, the SUNCOM maintenance man was able to reattach the faucet handle. It is now in good repair. (Attachment # 7 Photo). 02/29/2024 Implemented
2380.83(a)The Emergency Evacuation Procedures do not include individual responsibilities.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.The Director of Compliance revised the Evacuation procedure to include the individuals responsibilities. (Attachment # 8 Evacuation Procedure) Staff were trained on the new Evacuation procedures. (Attachment # 9 ¿ Training Sheet) 03/01/2024 Implemented
2380.176(a)Personally Identifiable Information was found unlocked in the filing cabinet outside of the staff offices.Individual records shall be kept locked when they are unattended.It is the responsibility of the all staff to ensure compliance with this regulation by keeping individual records locked when unattended. Staff were re- trained in the requirements of regulation 2380.176(a). (Attachment # 10 -Training sheet & Attachment # 11 - Memo) 02/29/2024 Implemented
2380.181(e)(7)Individual # 1's 02/08/23 assessment does not assess the ability to sense heat sources.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.It is the responsibility of the Program Specialist to ensure compliance with this regulation 2380.181(e)(7) and ensure that the required information is documented in each clients Assessment, specifically the individuals knowledge of the dangers of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated, per regulation 2380.181 (e)(7). Assessment. The Program Specialist was trained in the requirements of regulation 2380.181, specifically (e)(7). (Attachment # 12 -Training sheet & Attachment # 13 - Memo) An Assessment Addendum for Individual #1¿s was completed on 02/16/2024 to revise the 02/08/2023 Assessment to include assessment of client¿s ability to sense heat sources. (Attachment # 14 ¿ Assessment Addendum) An email was sent on 03/01/2024 to the Supports Coordinator for Individual # 1 ¿ notifying them of the revisions. (Attachment # 15¿ E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will comply with regulation 2380.181(e)(7) by 03/15/2024. 03/15/2024 Implemented
SIN-00217114 Renewal 01/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(10)Fluid restrictions in Individual #1's current LMH states 48oz day; Individual #1 is on a 60oz a day restriction per her individual plan.The assessment must include the following information: A lifetime medical history.The Program Specialist is responsible to ensure that each assessment contains all required information per regulation 2380.181 (e)(12). Assessment, specifically Lifetime Medical History. The Program Specialist was trained in the requirements of regulation 2380.181(e) (10). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) An Assessment Addendum was completed for Individual #1 on 01/31/2023, revising the 02/02/2022 Assessment to include the Lifetime Medical History (revision completed on 01/26/2023), specifically addressing Individual #1¿s fluid restrictions. (Attachment # 3 Assessment Addendum) (Attachment # 4 Lifetime Medical History) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 02/17/2023. 02/17/2023 Implemented
SIN-00175862 Renewal 09/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The water that was measured at the woman's bathroom in area one was 136 degrees at the time of inspection.Hot water temperatures in areas accessible to individuals may not exceed 120°F.The Director, Lead Direct Service Worker, Program Specialists and Direct Service Workers were trained in the requirements of regulation 2380.59(b). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) The Lead Direct Service Worker (or designee) is responsible to take the daily water temperature each day. The Lead Direct Service Worker (or designee) is responsible to record the temperature on the Water Temperature Log. (Attachment #3 - Temperature Log) The Lead Direct Service Worker (or designee) is responsible to immediately notify the Director (or Program Specialist in the absence of the Director) if the water temperature exceeds 120°F. During the course of staffs workday, if they notice safety concerns including water temperature too high or too low, they are to notify the Program Specialist or Manager immediately. To ensure the water temperature continues to be properly regulated, the Kratzer Oil Company was contacted on Friday, 09/11/2020 to check the water heaters. On Monday, 09/14/2020 the Kratzer Oil Company employees added a mixing valve to the boiler to better regulate the water temperature. (Attachment # 4 Invoice) 09/14/2020 Implemented
SIN-00153491 Renewal 04/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)CVS/Equate sunscreen was located in a filing cabinet unlocked. Contact poison control was located on the label.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.It is the responsibility of the Program Specialists and Direct Service Workers to ensure that poisonous materials are kept locked or made inaccessible to individuals, when not in use per regulation 2380.53(a). The Program Specialists and Direct Service Workers were trained in the requirements of regulation 2380.53(a). (Attachment # 23 -Training sheet & Attachment # 24 - Memo) Upon discovery during licensing, the sunscreen was removed from the program. All poisons, including sunscreen will be locked up/made inaccessible. 04/05/2019 Implemented
2380.58(a)Room # 3 has 3x3 foot area stain on ceiling.Floors, walls, ceilings and other surfaces shall be in good repair.The Director, Program Specialist (PS) and Direct Service Workers are responsible to ensure the ¿floors, wall, ceilings and other surfaces are free of hazards¿ per regulation 2380.58(a) ¿Surfaces. Staff as trained in the requirements of regulation 2380.58(a). (Attachment # 20 -Training sheet & Attachment # 21 - Memo) The Direct Service Workers are responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Program Specialist. The Program Specialist is responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Director. The Director is responsible to ensure that the necessary repairs are made so that all surfaces are in good repair and free of hazards. Room 3 Ceiling tiles will be repaired by 05/15/2019. (Attachment # 22 ¿ Photo ¿ will be send upon completion) 05/15/2019 Implemented
2380.173(1)(ii)Individual # 1's record does not include identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The Program Specialists are responsible to ensure compliance with this regulation and ensure that the required information is documented in each client¿s record, specifically identifying marks. This personal information is to be documented on the Intake form. The Intake form is considered a permanent part of the individual record therefore the Intake form should not be purged. The Program Specialists were trained in the requirements of regulation 2380.183(7)(iii). (Attachment # 16 -Training sheet & Attachment # 17 - Memo) In review of the record, the identifying marks was documented on the Personal Intake Information form, however it was not included on the Emergency Care form. The Emergency Care form was revised on 04/25/2019 to include identifying marks. (Attachment #18 ¿ Intake form & Attachment #19 ¿ Emergency Care form) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/30/2019. 06/30/2019 Implemented
2380.173(9)Individual # 1's ISP updated 3/28/19 states he has 5 minutes alone time to use the bathroom. It needs to include the needed supervision during meals and snack time. Individual # 1's assessment 6/15/18 states he is a risk for choking. His food needs to be cut in bite size pieces. He has a tendency to eat too fast and benefits from prompts to eat slowly. He uses a spoon to eat. However, Individual # 1's physical dated 5/8/18 states he is also to avoid bread, soda, and pasta. He is to limit sweets, and sugary drinks. Individual # 1's ISP review 2/12/19 states he is a choking risk. Cut sandwiches 4 equal parts, other foods are no bigger than ½ by ½ inch size. He is to be supervised during all meals and snack times. Individual # 1's 11/13/18 and 8/13/18 ISP Reviews state Individual # 1 is given privacy in the bathroom, but staff wait outside the door in order to walk with him safely back to his program table. Individual # 3's assessment dated 05/16/18 identifies current diagnosis as Psychotic D/O, Anxiety. Those diagnosis are not contained in current physical exam.Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Specialist is responsible to ensure that the individual¿s record includes documentation of any identified discrepancy in the ISP or ISP Revision. If there is content discrepancy identified in the plan, there should be documentation that the discrepancy was communicated to the Plan Lead or SC per 2380.173(9). The Program Specialist was trained in the requirements of regulation 2380.173(9). (Attachment # 7 -Training sheet & Attachment # 8 - Memo) A letter of Content Discrepancy, dated 05/06/2019 was emailed to the Supports Coordinator of information to be added to the ISP clarifying individual #1¿s supervision, specifically during meals and snack time. (Attachment # 9- Content Discrepancy Letter and Attachment #10 - Email to Supports Coordinator) An Assessment Addendum for 06/15/2018 was completed on 05/06/2019 clarifying Individual #1¿s diet ensuring that the 05/08/2018 physical and the Assessment include the same information. The Assessment Addendum was emailed to the Supports Coordinator. (Attachment # 11 ¿ Assessment Addendum & Attachment # 10 - Email to Supports Coordinator) An ISP Review Addendum for the 02/12/2019 ISP Review was completed on 05/06/2019, clarifying Individual #¿s diet and supervision while eating. The ISP Review Addendum was emailed to the Supports Coordinator. (Attachment # 12 ¿ ISP Review Addendum & Attachment # 10 - Email to Supports Coordinator) ISP Review Addendum¿s for the 11/13/2018 and 08/13/2019 ISP Reviews were completed on 05/06/2019 clarifying Individual #1¿s supervision care needs. Assessment Addendums were emailed to Supports Coordinator. (Attachment # 13 ¿ 11/13/2018 ¿ ISP Review Addendum, Attachment # 14 ¿ 08/13/2018 ¿ ISP Review Addendum & Attachment # 10 - Email to Supports Coordinator) Individual # 3's assessment dated 05/16/18 identifies current diagnosis as Psychotic D/O, Anxiety. Those diagnoses were not contained in current physical exam. Individual #3¿s 05/16/2018 Assessment contained the current diagnosis as Psychotic D/O and Anxiety. The 04/01/2019 Physical did not include the Lifetime Medical History, which listed all diagnoses. The Lifetime Medical History was attached to the Physical Examination on 05/06/2019. (Attachment # 15 ¿ Physical Exam/Lifetime Medical History) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/30/2019. 06/30/2019 Implemented
2380.176(a)Individual records were unlocked in 1:1 area including Residential log,Progress notes, service notes, ISP, BP, Daily Progress notes, Programming book. Community Integration Log with individual names and outings left in kitchen by art cabinet.Individual records shall be kept locked when they are unattended.It is the responsibility of the all staff to ensure compliance with this regulation and ensure that individual records are kept confidential and locked when unattended. Diane Black, Director met with staff on 04/05/2019, following the onsite licensing to verbally review the importance of keeping individual records locked when unattended. Staff also reviewed a memo and signed a training sheet indicating they were trained in the requirements of regulation 2390.176(a). (Attachment # 5 -Training sheet & Attachment # 6 - Memo) CORRECTION DATE: 04/05/2019 04/05/2019 Implemented
2380.181(e)(12)Individual # 1's assessment dated 6/15/18 does not include recommendations for specific areas of training , vocational programing, and competitive community integrated employment is Blank.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The Program Specialist is responsible to ensure recommendations for specific areas of training, vocational programming and competitive community-integrated employment are included in the Assessment per regulation 2380.181 (e)(12). ¿ Assessment. The Program Specialists were trained in the requirements of regulation 2380.181(e) (12). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) An Annual Assessment Addendum was completed for Individual #1 on 04/25/2019, revising the 06/15/2018 Assessment to include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. (Attachment # 3 ¿ Annual Assessment Addendum) An e-mail was sent 05/08/2019 to the Supports Coordinator for Individual # 1 ¿ notifying them of the revisions. (Attachment # 4¿ E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 06/30/2019. 06/30/2019 Implemented
SIN-00133198 Renewal 04/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.83(a)The emergency evacuation plan did not include the means of transportation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. The Evacuation procedure was revised to include the means of transportation. (Attachment #19 ¿ Evacuation Procedure) 05/10/2018 Implemented
2380.111(c)(7)Individual #2's 7/28/17 physical exam did not include a medication regimen.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.55 PA Code Chapter 2380.111(c)(7)- Individual Physical Examination -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. The Program Specialist is responsible to ensure that each physical examination includes an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals per regulation 2380.111(c)(7). The Program Specialists were trained in the requirements of regulation. (Attachment #16- Training sheet & Attachment #17- Memo) Individual #2s (MM) physical dated 07/28/2017 did not include a medication regimen. The list of medications was attached to the physical examination on 05/08/2018. (Attachment #18- Physical Examination page 2 and Medication list) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 05/31/2018. 05/31/2018 Implemented
2380.181(d)Individual #1's 12/8/17 assessment was not signed or dated by the program specialist.The program specialist shall sign and date the assessment.55 PA Code Chapter 2380.181(d)- Assessment - The program specialist shall sign and date the assessment. The Program Specialist is responsible to sign and date the Assessment ensuring compliance with this regulation. The Program Specialists were trained in the requirements of regulation 2380.181(d). (Attachment # 12 -Training sheet, Attachment # 13 ¿ Memo, and Attachment #14 ¿Individual #1¿s (JM) signed 02/28/2018 Assessment) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 05/31/2018. 05/31/2018 Implemented
2380.181(e)(7)Individual #1's assessment did not include his ability to move away from heat sources.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.55 PA Code Chapter 2380.181(e)(7)- Assessment - The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client¿s Assessment, specifically the individual¿s knowledge of the dangers of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated, per regulation 2380.181 (e)(7). ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181, specifically (e)(7). (Attachment # 12 -Training sheet & Attachment # 13 - Memo) An Assessment Addendum was completed for Individual #1(JM), revising the 02/28/2018 Assessment clarifying the individual¿s and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. (Attachment # 15 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members. (Attachment #5 ¿ Email) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 05/31/2018. 05/31/2018 Implemented
2380.183(7)(i)Individual #1's Individual Support Plan (ISP) did not include his potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.55 PA Code Chapter 2380.183(7)(i)- Contents of the Individual Support Plan (ISP) The Individual Support Plan, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include: Assessment of the individual¿s potential to advance in the following: (i) Vocational Programming. The Program Specialist is responsible to ensure compliance with this regulation and ensure that the required information is documented in each client¿s ISP, specifically an assessment of the individual¿s potential to advance in the following: (i) Vocational Programming. The Program Specialists were trained in the requirements of regulation 2380.183(7)(i). (Attachment # 9 -Training sheet & Attachment # 10 - Memo) On 05/14/2018 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #1¿s (JM) ISP to include an assessment of the individual¿s potential to advance in Vocational programming. (Attachment #11 ¿ Email) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 05/31/2018. 05/31/2018 Implemented
2380.183(7)(iii)Individual #1's Individual Support Plan (ISP) did not include his potential to advance in competitive employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.55 PA Code Chapter 2380.183(7)(iii)- Contents of the Individual Support Plan (ISP) The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. The Program Specialist is responsible to ensure compliance with this regulation and ensure that the required information is documented in each client¿s ISP, specifically an assessment of the individual¿s potential to advance in the following: (iii) Competitive community integrated employment. The Program Specialists were trained in the requirements of regulation 2380.183(7)(iii). (Attachment # 9 -Training sheet & Attachment # 10 - Memo) On 05/14/2018 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #1¿s (JM) ISP to include an assessment of the individual¿s potential to advance in Competitive community integrated employment. (Attachment #11 ¿ Email) Program Specialists are in the process of 05/31/2018 Implemented
2380.185(b)Individual #1's Individual Support Plan (ISP and physician orders indicate he is to be repositioned every 2 to 3 hours. There is no documentation the repositioning occurred until April of 2018.The ISP shall be implemented as written.55 PA Code Chapter 2380.185(b)- Implementation of the Individual Support Plan (ISP) ¿ the ISP shall be implemented as written. The Program Specialist is responsible to ensure the ISP is implemented as written per regulation. The Program Specialists were trained in the requirements of regulation 2380.185(b). (Attachment # 6-Training sheet & Attachment # 7- Memo) Program Specialists are responsible to review each individual¿s ISP to ensure the ISP is being implemented as written for regulation 185(b). An example would include daily documentation regarding every 2-3 hour body repositioning. (Attachment # 8- Individual #1 (JM¿s) April 2018 body repositioning chart) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 05/31/2018. 05/31/2018 Implemented
2380.186(c)(1)Individual #1's 12/29/17 and 3/29/18 Individual Support Plan (ISP) reviews did not include progress toward the ISP outcome of friendships.The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.55 PA Code Chapter 2380.186(c)(1) ¿ISP review and revision- The ISP review must include the following: (c)(1) A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months towards ISP outcomes supported by services provided by the provider. The Program Specialists are responsible to ensure that the Individual Support Plan (ISP) Review includes a review of each section of the ISP, progress toward their outcome. The Program Specialists were trained in the requirements of regulation 2380.186(c)(1). (Attachment # 1-Training sheet & Attachment # 2- Memo) Individual #1's (JM) Individual Support Plan (ISP) reviews dated 12/29/2017 and 03/29/2018 did not indicate progress toward his outcome. ISP Review Addendum notes were completed to include documentation of the individual¿s progress toward his outcome for the ISP Reviews for 12/29/2017 and 03/29/2018. (Attachment # 3 ¿ 12/29/2017 ISP Review Addendum and Attachment # 4 - 03/29/2018 ISP Review Addendum) An e-mail was sent to the Supports Coordinator for Individual # 1 ¿ notifying them of the revisions. (Attachment # 5 ¿ E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 05/31/2018. 05/31/2018 Implemented
SIN-00113657 Renewal 05/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The fire drill held on 1/30/2017 had an evacuation time of 4 minutes and 54 seconds which is over the recommended evacuation time by the fire safety expert of 4 minutes. No other fire drill was documented in January of 2017.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.55 PA Code Chapter 2380.89(d) ¿ Fire Drills - Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The fire safety expert may not be an employee of the facility or of the legal entity of the facility. The Program Specialist is responsible to ensure that when a fire drill exceeds the evacuation time allowed by the fire safety expert (4 minutes) then a repeat fire drill shall occur within the same month and be documented in the fire drill record. The Program Specialists were trained in the requirements of regulation 2380.89(d). (Attachment # 17 -Training sheet & Attachment # 18 - Memo) 07/05/2017 Implemented
2380.113(c)(3)Staff #1's physical dated 5/16/16 did not state if he/she was free of serious communicable diseases.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.55 PA Code Chapter 2380.113(c)(3)- Staff physical examination. (c) The physical examination shall include: (3) 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. The CEO or ATF/ATW Director is responsible to ensure compliance of staff physical examinations, including a signed statement that the person is free of serious communicable diseases or specific precautions are taken that will prevent spread of disease to individuals. The CEO was trained in the requirements of regulation 2380.113(c) (3). (Attachment # 14 -Training sheet & Attachment # 15 - Memo) A physician¿s note dated 06/12/2017 addressed Staff #1¿s status of communicable diseases. The note was attached to Staff #1¿s 05/16/2016 physical. (Attachment #16 ¿ Physician note) 06/30/2017 Implemented
2380.181(e)(10)Individual #1's assessment completed on 3/29/2017 did not include his/her lifetime medical history.The assessment must include the following information: A lifetime medical history.55 PA Code Chapter 2380.181(e)(10) ¿Assessment - The assessment must include the following information: A lifetime medical history. The Program Specialist is responsible to ensure the lifetime medical history is attached to the assessment per regulation 2380.181 (e)(10). ¿ Assessment. The Program Specialists were trained in the requirements of regulation 2380.181(e) (10). (Attachment # 7 -Training sheet & Attachment # 8 - Memo) Individual # 1¿s 03/29/2017 Assessment was updated on 05/24/2017 to include lifetime medical history. (Attachment #9 ¿ Assessment) The Lifetime Medical History was attached to the Assessment and the current Physical on 05/24/2017. Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 07/31/2017. 07/31/2017 Implemented
2380.181(e)(12)Individual #2's assessment completed 1/20/17 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. The section states "There are no specific recommedations for training, vocational programming or competitive employment at this time."The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.55 PA Code Chapter 2380.181(e)(12) ¿ Assessment -The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. The Program Specialist is responsible to ensure recommendations for specific areas of training, vocational programming and competitive community-integrated employment are included in the Assessment per regulation 2380.181 (e)(12). ¿ Assessment. The Program Specialists were trained in the requirements of regulation 2380.181(e) (12). (Attachment # 10 -Training sheet & Attachment # 11 - Memo) An Annual Assessment Addendum was completed for Individual #2 on 07/06/2017, revising the 01/20/2017 Assessment to include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. (Attachment # 12 ¿ Annual Assessment Addendum) An e-mail was sent 07/18/2017 to the Supports Coordinator for Individual # 2 ¿ notifying them of the revisions. (Attachment # 13¿ E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 07/31/2017. 07/31/2017 Implemented
2380.186(c)(2)Individual #2 has a seizure protocol. The following Individual Support Plan reviews do not address the protocol: 12/30/2016, 9/30/2016 and 6/30/2016.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.55 PA Code Chapter 2380.186(c)(2) ¿ISP review and revision- The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. The Program Specialist is responsible to ensure that the Individual Support Plan (ISP) Review includes a review of each section of the ISP, specifically seizure protocol. The Program Specialist was trained in the requirements of regulation 2380.186(c)(2). (Attachment # 1-Training sheet & Attachment # 2- Memo) Individual # 2 an ISP Review Addendum note was completed on 07/06/2017 to include documentation of the individual¿s seizure protocol for the ISP Reviews for 06/30/2016, 09/30/2016 and 12/30/2016. (Attachment # 3 ¿ 06/30/2016 ISP Review Addendum, Attachment # 4 - 09/30/2016 ISP Review Addendum and Attachment # 5 - 12/30/2016 ISP Review Addendum) An e-mail was sent 07/18/2017 to the Supports Coordinator for Individual # 2 ¿ notifying them of the revisions. (Attachment # 6 ¿ E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 07/31/2017. 07/31/2017 Implemented
SIN-00094913 Renewal 06/11/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The first aid area the green table cloth is torn with approximatly ten holes. Room 2 and has markes on walls. The non-skid on the floor in the bathroom is peling. Floor from kitchen to room 4 os missing piece of tile. Floors, walls, ceilings and other surfaces shall be in good repair.The Program Specialist (PS) and Direct Service Workers are responsible to ensure the ¿floors, wall, ceilings and other surfaces are free of hazards¿ per regulation 2380.58(a) ¿Surfaces. The Program Specialists were trained in the requirements of regulation 2380.58(a). (Attachment #20 -Training sheet & Attachment #21 - Memo) The Direct Service Workers are responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Program Specialist. The Program Specialist is responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Director. The Director is responsible to ensure that the necessary repairs are made so that all surfaces are in good repair and free of hazards. First Aid table was replaced on 06/20/2016. (Attachment #22 - Photo) Room 2 ¿ marks on the walls were repaired on 08/08/2016. (Attachment #23 ¿ Photo) Room 2 bathroom ¿ non skid strips reapplied on 08/19/2016. (Attachment #24 ¿ Photo) Floor from kitchen into room 4 ¿ missing floor tiles were replaced on 08/29/2016. (Attachment #25 ¿ Photo) 08/29/2016 Implemented
2380.72(b)The macadam gravel outside the exit door to parking area is crumbling and uneven. The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.The Program Specialist (PS) and Direct Service Workers are responsible to ensure the ¿The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions¿ per regulation 2380.72(b) ¿Exterior conditions. The Program Specialists and Direct Service Workers were trained in the requirements of regulation 2380.72(b). (Attachment #17 - Training sheet & Attachment #18 - Memo) The Direct Service Workers are responsible to report unsafe conditions and when the facility grounds/outside of the building is not in good repair to the Program Specialist. The Program Specialist is responsible to report unsafe conditions and when the facility grounds/outside of the building is not in good repair to the Director. The Director is responsible to ensure that the necessary repairs are made so that the exterior conditions are well maintained, in good repair and free of unsafe conditions. The gravel that was broken and crumbling was removed on 06/13/2016, thus eliminating the unsafe condition. (Attachment #19 ¿ Photo) 06/13/2016 Implemented
2380.173(9)Individual #3's seizure protocol states after 5 minutes give 10mg diastat and after another 5 minutes give again. Call 911 if 2nd dose administred. The ISP states 2mg lorzepam for seizures over 10 minutes 1 mg after 20 minutes er after 1 hour. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Program Specialist is responsible to ensure that the individual¿s record includes documentation of any identified discrepancy in the ISP or ISP Revision. If there is content discrepancy identified in the plan, there should be documentation that the discrepancy was communicated to the Plan Lead or SC per 2380.173(9). The Program Specialist was trained in the requirements of regulation 2380.173(9). (Attachment # 14 -Training sheet & Attachment # 15 - Memo) Individual #3¿s seizure protocol and ISP did not match. The content discrepancy between the ISP and the Seizure protocol was resolved on 08/29/2016. (Attachment #16 ¿Content Discrepancy letter e-mailed to SC and team) The Program Specialist is in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016. 08/29/2016 Implemented
2380.181(e)(10)Individual #4's assessment dated 10/19/15 did not include life time medical history. The assessment must include the following information: A lifetime medical history.The Program Specialist is responsible to ensure the lifetime medical history is attached to the assessment per regulation 2380.181 (e)(10). ¿ Assessment. The Program Specialists were trained in the requirements of regulation 2380.181(e) (10). (Attachment # 8 -Training sheet & Attachment # 9 - Memo) Individual # 4¿s Assessment was updated on 08/29/2016 to include lifetime medical history. (Attachment #10 ¿ Assessment) The assessment was sent to the Supports Coordinator and plan team members. Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016 08/29/2016 Implemented
2380.181(e)(13)(i)Individual #4's assessment dated 10/19/15 did not include progress and growth over the last 365 calendar days and current level in health. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13) ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, and v). (Attachment # 11-Training sheet & Attachment #12- Memo) Individual #4¿s assessment was updated on 08/29/2016 to include progress and growth over the last 365 calendar days in the areas of health, motor and communication skills, personal adjustment, socialization and recreation. (Attachment #13 ¿ Assessment) The assessment was sent to the Supports Coordinator and plan team members. Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016. 08/29/2016 Implemented
2380.181(e)(13)(ii)Individual #4's assessment dated 10/19/15 did not include progress and growth over the last 365 calendar days and current level in motor and communication.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13) ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, and v). (Attachment # 11-Training sheet & Attachment #12- Memo) Individual #4¿s assessment was updated on 08/29/2016 to include progress and growth over the last 365 calendar days in the areas of health, motor and communication skills, personal adjustment, socialization and recreation. (Attachment #13 ¿ Assessment) The assessment was sent to the Supports Coordinator and plan team members. Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016. 08/29/2016 Implemented
2380.181(e)(13)(iii)Individual #4's assessment dated 10/19/15 did not include progress and growth over the last 365 calendar days and current level in personal adjustment. 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.The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13) ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, and v). (Attachment # 11-Training sheet & Attachment #12- Memo) Individual #4¿s assessment was updated on 08/29/2016 to include progress and growth over the last 365 calendar days in the areas of health, motor and communication skills, personal adjustment, socialization and recreation. (Attachment #13 ¿ Assessment) The assessment was sent to the Supports Coordinator and plan team members. Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016. 08/29/2016 Implemented
2380.181(e)(13)(iv)Individual #4's assessment dated 10/19/15 did not include progress and growth over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13) ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, and v). (Attachment # 11-Training sheet & Attachment #12- Memo) Individual #4¿s assessment was updated on 08/29/2016 to include progress and growth over the last 365 calendar days in the areas of health, motor and communication skills, personal adjustment, socialization and recreation. (Attachment #13 ¿ Assessment) The assessment was sent to the Supports Coordinator and plan team members. Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016. 08/29/2016 Implemented
2380.181(e)(13)(v)Individual #4's assessment dated 10/19/15 did not include progress and growth over the last 365 calendar days and current level in recreation. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The Program Specialist is responsible to ensure the assessment contains all necessary requirements per regulation 2380.181 (e)(13) ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181(e) (13) (i, ii, iii, iv, and v). (Attachment # 11-Training sheet & Attachment #12- Memo) Individual #4¿s assessment was updated on 08/29/2016 to include progress and growth over the last 365 calendar days in the areas of health, motor and communication skills, personal adjustment, socialization and recreation. (Attachment #13 ¿ Assessment) The assessment was sent to the Supports Coordinator and plan team members. Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016. 08/29/2016 Implemented
2380.186(c)(2)Individual #3's ISP reviews dated 4/7 and 10/3 did not review seizure protocol/ anxiety. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Specialist is responsible to ensure that the Individual Support Plan (ISP) Review includes a review of each section of the ISP, specifically seizure protocol/anxiety. The Program Specialist was trained in the requirements of regulation 2380.186(c)(1)(2). (Attachment # 1-Training sheet & Attachment # 2- Memo) Individual # 3 an ISP Review Addendum note was completed on 8/29/2016 to include documentation of the individual¿s seizure and anxiety protocols for the ISP Reviews from 04/07/2016 and 10/07/2015. (Attachment # 3 ¿ 04/07/2016 ISP Review Addendum and Attachment # 4 - 10/07/2015 ISP Review Addendum) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 8/29/2016. 08/29/2016 Implemented
2380.186(e)Individual #3's had no option to decline the ISP reviews. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The Program Specialist is responsible to notify the plan team members of the option to decline the ISP review documentation. The Program Specialist was trained in the requirements of regulation 2380.186(e). (Attachment # 5-Training sheet & Attachment # 6- Memo) Individual #3 The Option to Decline form was sent to all team members to document team member¿s decision to decline to receive the ISP Reviews. (Attachment # 7 - Option to Decline form) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 08/29/2016 08/29/2016 Implemented
SIN-00060448 Renewal 03/10/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #2 and Staff #3 did not complete annual fire safety training in the regulatory timeframe. Staff #2 and Staff #3 received training on 10/8/2012 and not again until 10/14/2013. (f)  Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).The Director of Compliance is responsible to ensure that the Program Specialists and Direct Service Workers are trained annually (at least once every 12 months) by a fire safety expert. The Director of Compliance was trained in the responsibility and requirements of regulation 36(f). (Attachment A - Training sheet & B - Memo) 05/30/2014 Implemented
2380.58(b)The bathroom located at the end of the hall near the side exit had a soap dispenser laying on the sink. There is 2 patches on each side of the mirror where the paint had peeled off. (b)  Floors, walls, ceilings and other surfaces shall be free of hazards.The Program Specialists are responsible to ensure that the floors, walls, ceilings and other surfaces are free of hazards. The Program Specialists were trained in their responsibilities. (Attachment C -Training sheet & D-Memo) Photo of patched wall and soap dispenser remounted. (Attachment E) 06/02/2014 Implemented
SIN-00046509 Renewal 03/13/2013 Compliant - Finalized