Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00267502 Renewal 06/03/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(5)Individual #1's assessment, last updated 7/25/2024, does not include a complete assessment of the Individual being able to self-administer medication or why the Individual is only able to self-administer a weekly injection and not the oral medications.The assessment must include the following information:  The individual's ability to self-administer medications.The Program Specialist updated Individual #1¿s assessment on 6/10/2025 to include a complete and detailed explanation of the individual¿s ability to self-administer medications. The update specifies that the individual is capable of self-administering a weekly injection but is unable to self-administer oral medications due to the volume of oral medications prescribed and inability to distinguish the pills. The updated assessment includes justification for this distinction and has been reviewed with all relevant team members. 06/10/2025 Implemented
SIN-00247191 Renewal 06/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1 had a physical examination completed on 9/22/23, that did not address medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The program specialist has sent the physical form to the PCP office for Individual #1 to have pertinent medical information in case of an emergency added to the physical. 07/02/2024 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. The medication reviews completed on 10/31/23, 12/15/23, 3/5/24, 3/15/24, 4/19/24, and 6/10/24, did not include the following: a list of the specific medications that had been reviewed; the diagnosis or purpose for prescribing the medication; and the need to continue the medication as well as their necessary dosages.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.AACS management team and program specialist were retrained on 55 PA Code Chapter 6400.165 (g). A complete medication list will be added to all psychiatric forms with the reason of why the medication is being prescribed, the need to continue the medication, along with the dosage of the mediation to be given at a specific time period. Reviews will continue to occur at lease every 3 months. 07/01/2024 Implemented
SIN-00227941 Renewal 07/18/2023 Compliant - Finalized