Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225294 Renewal 05/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #3's Tetanus, Diphtheria, and Pertussis vaccinations were completed on 3/27/2012 and again on 9/14/2022.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.As identified, individual #3 had his Tetanus, Diphtheria, Pertussis vaccine on 9/14/22 so he is good. The BLARS Lead nurse will double check all of the other clients to assure they are within the stipulated time frame for their vaccines. 07/21/2023 Implemented
2380.111(c)(6)Individual #2's annual physical examination, completed 5/1/2023, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was left blank.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.The BLARS nursing staff will reach out to individual #2's PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (specific precautions that shall be taken if the individual has a serious communicable disease). 07/21/2023 Implemented
2380.111(c)(8)Individual #1's physical examination, completed 6/14/2022, did not include physical limitations of the individual. This section was left blank. Individual #2's physical examination, completed 5/1/2023, did not include physical limitations of the individual. This section was left blank.The physical examination shall include: Physical limitations of the individual.The BLARS nursing staff will reach out to individual #2's PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (physical limitations of the individual) 07/21/2023 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 6/14/2022, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination, completed 5/1/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The BLARS nursing staff will reach out to individual #1's PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (Medical information pertinent to diagnosis and treatment in case of an emergency). 07/21/2023 Implemented
2380.111(c)(11)Individual #1's physical examination, completed 6/14/2022, did not include special instructions for the individual's diet. This section was left blank. Individual #2's physical examination, completed 5/1/2023, did not include special instructions for the individual's diet. This section was omitted from the examination form that was provided to the primary care practitioner.The physical examination shall include: Special instructions for an individual's diet.The BLARS nursing staff will reach out to individual #1' and #2's PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (instructions for the individual's diet). 07/21/2023 Implemented
2380.36(b)Program Specialist #1 last received fire safety training from a fire safety expert on 4/4/2018.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The Program Specialist took fire safety training on 6/5/23; he is now in compliance. 07/03/2023 Implemented
2380.39(c)(1)Program Specialist #1 did not receive training on the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships during the 5/1/2022 - 4/30/2023 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The Program Director will receive training in the areas of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships the week of 6/19/23. 07/03/2023 Implemented
2380.39(c)(3)Program Specialist #1 did not receive training on individual rights during the 5/1/2022 - 4/30/2023 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The Program Director will receive training on individual rights the week of 6/19/23. 07/03/2023 Implemented
2380.39(c)(4)Program Specialist #1 did not receive training on recognizing and reporting incidents during the 5/1/2022 - 4/30/2023 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The Program Director will receive recognizing and reporting incidents training the week of 6/19/23. 07/03/2023 Implemented
SIN-00207738 Renewal 06/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Chief Executive Officer #1's most recent physical examination was completed on 06/15/18. Program Specialist #2's most recent physical examination was completed on 06/11/18.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.The Executive Director had his physical examination on 6/27/22 which also included the Tuberculin skin testing. The PPD was read by our Occupational RN on 6/29/22. The Program Specialist received his physical examination on 6/28/22 which also included the Tuberculin skin testing; his PPD was read by the Occupational RN on 6/30/22. [Employee Health Report Form for Chief Executive Officer #1, dated 6/29/22, received 7/19/22 and reviewed 7/22/22. Employee Health Report Form for Program Specialist #2, dated 7/1/22, received 7/19/22 and reviewed 7/22/22. DPOC by HDKP, HSLS, on 7/22/22.] 08/01/2022 Implemented
2380.113(c)(2)Chief Executive Officer #1's most recent tuberculin skin test was completed on 06/18/18. Program Specialist #2's most recent tuberculin skin test was completed on 06/13/18.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.The Executive Director had his physical examination on 6/27/22 which also included the Tuberculin skin testing. The PPD was read by our Occupational RN on 6/29/22. The Program Specialist received his physical examination on 6/28/22 which also included the Tuberculin skin testing; his PPD was read by the Occupational RN on 6/30/22. [Employee Health Report Form for Chief Executive Officer #1, dated 6/29/22, received 7/19/22 and reviewed 7/22/22 The Employee Health Report Form contained a tuberculin evaluation, dated 6/29/22. Employee Health Report Form for Program Specialist #2, dated 7/1/22, received 7/19/22 and reviewed 7/22/22. The Employee Health Report Form contained a tuberculin evaluation, dated 6/30/22. DPOC by HDKP, HSLS, on 7/22/22.] 08/01/2022 Implemented
SIN-00190317 Renewal 07/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(u)There is no record of Individual #1, date of admission 6/18/20, having been informed on individual rights and the process to report a rights violation. There is no record of Individual #2, date of admission 4/17/07, having been informed on individual rights and the process to report a rights violation.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The Ramsbottom Administration has reached out to the guardian of Individual #1 requesting that she review and sign off on the Individual Rights statement, sign and return to our office for filing. We currently do have a returned Individual Rights statement from individual #2 (this was completed on 7/28/21). A complete check of all other individuals was completed and three other cases were found where the statements were not returned following the initial mailing. These are in the process of being re-mailed to the guardian for review and signature. 08/06/2021 Implemented
SIN-00126578 Renewal 12/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)Chief executive officer #1, date of hire 5/16/88, had 9.75 hours of training relevant to human services or administration during the training year of 1/1/16 to 12/31/16.The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Each calendar year the Executive Director of Beacon Light Adult Residential Services (BLARS) will complete at least 24 hours of training. In addition to regularly scheduled training mandated by the agency, the Executive Director will also complete at least two (2) hours of training each month. Compliance in this area will be monitored by the Human Resources Department. Additionally the Executive Director will maintain a aggregate, monthly training record, authenticated by a member of the Human Resources Department each month as evidence of compliance. [In training year 1/1/17 to 12/31/17, CEO completed 5.75 and so far in training year 1/1/18 to 12/31/18, CEO completed 23 hours of training. Documentation of audits of training records by the HR Department shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
2380.113(c)(3)Direct Service Worker #2's physical examination completed 9/14/16 did not include: A signed statement that the person is free of serious communicable diseases. The form had a yes or no section that was not completed.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. [Staff Person #1 had an update physical examination to include a signed statement that the person is free of serious communicable diseases on XXXXXXX. Immediately and upon completion a designated Staff person shall review all staff person physical examinations to ensure all required information is included. Documentation of audits shall be kept. (ASThe physical exam form was redone by the Beacon Light Adult Residential Services (BLARS) Nurse Manager to address if the client is free from communicable diseases. This form will be sent with the client to their yearly physical; subsequently completed and signed by the physician. A member of the Nursing staff will insure that form is completed correctly and if not will work with the physician¿s office to see that if is completed correctly. This area will be monitored for compliance by the BLARS Nurse Manager and the Program Specialist. [Not acceptable, Plan of correction does not address Staff Person physical examinations. Direct Service Worker #2 physical examination was updated to address S/he is free of communicable disease. Upon completion of staff person's physical examinations, designated staff person trained in the required information of physical examinations as per 2380.113(c)1-4, shall audit all physical examinations to ensure all required information is included. Documentation of the audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
SIN-00105362 Renewal 12/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(d)Individual #1's assessment, completed 5/11/16, and Individual #2's assessment, competed 8/10/16, were not signed and dated by the program specialist.The program specialist shall sign and date the assessment.All of the assessments in the Adult Day Services Program have been checked for signatures and dates including Individual #1 and Individual #2. All are in compliance. Effective January 2017, the Program Specialist will sign and date each assessment following the completing of the document. Additionally, the Program Specialist will sign off on the ¿Assessment Schedule Documentation Form¿ and the ¿IPP Check List Form¿ as a ¿double check¿ to ensure compliance. This process will occur at the completion of each assessment. These forms are maintained in the Program Specialist¿s office. This area will be monitored by the Program Specialist and Director of IDD for compliance. [At least quarterly for 1 year, the Director of IDD will review a 25% sample of completed assessments to ensure the program specialist signs and dates all individuals' assessments. (AS 1/19/17)] 01/15/2017 Implemented
SIN-00067826 Renewal 11/19/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)Staff person #1, the program CEO, had 11.75 hours of training relevant to human services or administration for the 2013 training year.The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Effective 1/1/15, the Ramsbottom Executive Director will obtain at least 24 hours of training relevant to human services or administration annually. The Executive Director will enroll in the January 2015 training schedule as well as take outside trainings which will be used to satisfy the regulatory training requirements. The Executive Director¿s training hours will be monitored by the Human Resources Department and will be documented on a staff fact sheet that is distributed monthly. In subsequent years, the Executive Director will obtain all training hours in the first quarter of each calendar year; this will be documented on the employee¿s staff fact sheet. The Human Resources Department is responsible for monitoring this area for compliance. [In addition to the 24 hours of training required for the 2015 training year, the CEO will complete an additional 12.25 hours during the 2015 training year. (CHG 12/9/14)] 11/30/2014 Implemented
SIN-00052292 Renewal 12/11/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.90(b)The exit sign over the front door is not immediately visible from the hallway leading to the door.(b)  If the exit or way to reach the exit is not immediately visible to the individuals, access to exits shall be marked with visible signs indicating the direction of travel.Prior to the completion of the inspection on 12/11/13, the Adult Day Services Director had positioned signs in the hallways with directions (arrows indicating the direction of travel) leading to the actual exit. Each month, the ADS Director will visually inspect these signs to ensure they are positioned properly and have not become damaged or removed for any reason. The ADS Director will document on a Life Safety check sheet that this inspection has been completed (monthly). The ADS Director will communicate this inspection to the Executive Director monthly. 12/21/2013 Implemented
SIN-00265298 Renewal 04/22/2025 Compliant - Finalized
SIN-00243884 Renewal 05/02/2024 Compliant - Finalized
SIN-00165524 Renewal 11/05/2019 Compliant - Finalized
SIN-00146331 Renewal 11/30/2018 Compliant - Finalized
SIN-00086588 Renewal 11/18/2015 Compliant - Finalized