Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240240 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1 was instructed in general fire safety 1/03/2022 and then again 5/08/2023.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.During the May 2023 chart reviews, it had been observed that this individual's annual fire safety training was not completed as required, and the training was completed immediately upon discovery. 03/18/2024 Implemented
SIN-00225215 Unannounced Monitoring 05/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.127(a)(1)Individual #2's prescribed Clorhex Glu Solution 0.12%, was not administered 5/18/2023 at 12:00pm. Individual #2's May 2023 medication administration record documents that the 5/01/2023 12:00pm administration of the Clorhex Glu Solution 0.12% was unavailable to give.Medication errors include the following: Failure to administer a medication.ATF Director retrained staff on proper utilization of the electronic medication record (QuickMar) for administering medications in their given times frames in addition to action taken when medication is not present at the day program. ATF Director also retrained on the classroom checklists, it's location and individuals who have medications and at what time the medication is administered. 07/07/2023 Implemented
2380.186Individual #1's individual support plan, last updated 4/05/2023, states the individual has a seizure disorder and seizures can occur with any slight noise or variation in the environment, and due to her seizure disorder and risk these seizures pose to safety, the individual wears a helmet while ambulating as she is prone to drop seizures and support staff try and control her environment. The individual has a Vagus Nerve Stimulator (VNS) to help prevent the onset of seizures. On 5/18/2023 during staff interviews there were staff unaware of Individual #1's Vagus Nerve Stimulator and did not receive specific training regarding Individual #1's seizure protocol. Individual #3's assessment completed 11/21/2022 states she is on a pureed diet, uses a spoon, and doppler for drinks. Individual #3's individual support plan, last updated 5/15/2023, states the individual must be positioned at a 10% angle in wheelchair to eat, she eats lunch for 1 hour with water and food to be alternated during meals by her staff. It states that a 5ml dropper is to be used to administer water and she sits in an upright position for 30 minutes after lunch. On 5/18/2023 during staff interviews it was found that staff were not trained specifically on Individual #3's feeding protocol.The facility shall implement the individual plan, including revisions.On 5/22/23, all ATF staff were trained by Director of Community Health on how to use Vagus Nerve Stimulator (VNS) relating to the individual #1 specific seizure protocol. On 5/26/23 ATF Director received updated Seizure protocol and on 5/30/23 all ATF staff were trained by the ATF Director and Director of Community Health on Individual #1 seizure protocol and Individual #3 eating protocol. 05/30/2023 Implemented
SIN-00221525 Renewal 03/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(c)(1)Program Specialist #1, date of hire 2/22/23, does not have the work experience required for the program specialist postion.A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with persons with disabilities.A background collection and analysis of the Program Specialist¿s #1 (PS) qualifications and process for hire was completed. All other Program Specialists/Clinical Specialists qualifications were reviewed, along with validating qualifications identified in the Job Descriptions with the regulations (and waiver amendments). The PS #1 submitted a resume to PathWays during the application process which was later updated (i.e., master¿s degree complete, company name added, description of work performed, etc.). During inspection the original resume was provided. PathWays verified dates of employment. The PS #1 communicated with Human Resources regarding work history/experience with persons with disabilities included in the current resume which reflects more than 1 year experience. (Both documents will be sent via email). 05/01/2023 Implemented
SIN-00148036 Renewal 01/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(a)The program specialist completed the ISP review ending 3/8/18 for Individual #1 on 4/6/18. The program specialist completed the ISP review ending on 2/27/18 for Individual #2 on 3/28/18.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 individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.ATF Director will develop a centralized folder/binder which compiles the list of ISP review period dates when reviews are completed by the program specialists; completion dates with individual review and signature and other (i.e. direct care staff) review and signature; and date that completed ISP review is sent to individuals' team (as applicable). This centralized location will allow for ensuring that time frames are met when staff are off or when individuals are absent. All program specialists will place any ISP reviews in the location with notes about specific events that need to occur and the time frame. Currently, program specialists do not utilize one central tracking system - some use paper calendar, some electronic - which may create difficulty in tracking time frames when program specialists are off and/or when individuals are absent and report can't be reviewed with them. [Within 30 days of receipt of the plan of correction, the ATF Director shall educate the program specialists of the aforementioned tracking system and the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the ATF Director shall audit the aforementioned tracking system and a 10% sample of ISP review to ensure completion, timely. (DPOC by AES,HSLS on 2/1/19)] 02/01/2019 Implemented
2380.186(b)The program specialist and Individual #3 did not sign and date the ISP review ending on 12/18/18. The program specialist and Individual #4 did not sign and date the ISP review ending on 5/23/18.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.ATF Director will develop a centralized folder/binder which compiles the list of ISP review period dates when reviews are completed by the program specialists; completion dates with individual review and signature and other (i.e. direct care staff) review and signature; and date that completed ISP review is sent to individuals' team (as applicable). This centralized location will allow for ensuring that time frames are met when staff are off or when individuals are absent. All program specialists will place any ISP reviews in the location with notes about specific events that need to occur and the time frame. Currently, program specialists do not utilize one central tracking system - some use paper calendar, some electronic - which may create difficulty in tracking time frames when program specialists are off and/or when individuals are absent and report can't be reviewed with them. [Within 30 days of receipt of the plan of correction, the ATF Director shall educate the program specialists of the aforementioned tracking system and the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the ATF Director shall audit the aforementioned tracking system and a 10% sample of ISP reviews to ensure completion with required dates and signatures upon review of the ISP. (DPOC by AES,HSLS on 2/1/19)] 02/01/2019 Implemented
2380.186(d)The program specialist did not provide Individual # 2's ISP review ending 11/27/18 to the 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.ATF Director will develop a centralized folder/binder which compiles the list of ISP review period dates when reviews are completed by the program specialists; completion dates with individual review and signature and other (i.e. direct care staff) review and signature; and date that completed ISP review is sent to individuals' team (as applicable). This centralized location will allow for ensuring that time frames are met when staff are off or when individuals are absent. All program specialists will place any ISP reviews in the location with notes about specific events that need to occur and the time frame. Currently, program specialists do not utilize one central tracking system - some use paper calendar, some electronic - which may create difficulty in tracking time frames when program specialists are off and/or when individuals are absent and report can't be reviewed with them. [Within 30 days of receipt of the plan of correction, the ATF Director shall educate the program specialists of the aforementioned tracking system and the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the ATF Director shall audit the aforementioned tracking system and a 10% sample of ISP reviews and correspondence documentation to ensure the program specialists provide all individuals' ISP reviews to the plan team members as required. (DPOC by AES,HSLS on 2/1/19)] 02/01/2019 Implemented
SIN-00106471 Renewal 01/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)The two most recent physical examinations for Individual #1 were completed on 6/8/15 and 7/11/16.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Following the January 13, 2017 Licensing Inspection, the Program Specialists reviewed the time table for annual physical examinations. The next annual individual's physical examination is not due until January 27, 2017. Going forward, if physical examinations, including required immunizations, are not completed and submitted by the due date, the individual will be suspended from attending the program until the required information is received. The Program Specialists will ensure that all physical examinations are completed within the required time frame to ensure 100% compliance with 55 PA Code Chapter 2380.111(a). To ensure time frame is met, a central calendar was developed with the dates of all annual physical examinations as well as required immunizations. The calendar is checked daily to ensure all date requirements are met. (calendar was developed on January 20, 2017). Training regarding regulations and requirements was completed with the Program Specialists on January 26, 20217. [Immediately, the program specialist shall develop and implement a notification system to ensure all individuals are notified of due date of their required physical examination to ensure individuals have physical examination completed, timely. (AS 2/3/17)] 01/27/2017 Implemented
SIN-00088515 Renewal 01/08/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(d)Individual #1's ISP review documentation for 3/18/15 to 6/17/15 was sent to plan team members on 9/28/2015. Individual #2's ISP review documentation for 3/31/15 to 6/30/15 was sent to plan team members on 9/18/2015. Individual #3's ISP review documentation for 2/25/15 to 5/24/15 was sent to plan team members on 9/25/2015. Individual #4's ISP review documentation for 4/1/15 to 7/1/15 was sent to plan team members on 9/29/2015. Repeat Violation-1/5/2015The 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.Following the January 8, 2016 Licensing Inspection, there was 100% compliance with sending ISP review documentation reports within the required 30 day time frame. There were seven ISP review documentation reports that were sent out to SC or plan lead (as applicable) and plan team members within 30 calendar days from January 11, 2016 ¿ February 18, 2016. These reports had due dates from January 15, 2016 to February 4, 2016. Training regarding regulations and requirements was completed with the Program Specialists on February 19, 2016. An organizational flowsheet will be developed by ATF Assistant Director and ATF Director in conjunction with Pathways IT department for use of tracking and monitoring. The flowsheet will be available to all Program Specialists, Assistant Director and Director with report due dates and dates that reports are sent to plan team members including the SC or plan lead. The anticipated implementation date for the flowsheet is April 1, 2016; until the flowsheet is implemented, manual tracking will be completed by the Adult Training Facility Assistant Director and Director. 02/19/2016 Implemented
SIN-00073196 Renewal 01/05/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1's most recent physical exam, dated 12/16/2014, did not include vision or hearing screenings. The physical examination shall include: Vision and hearing screening, as recommended by the physician.Training was completed on the regulation. All physicals had this marked that we checked, other than the one found. However, we put in place for double checks of all physicals coming in to ensure complete. [CEO or designee will review all individuals' physicals to ensure all required elements are completed and will follow up to ensure missing information is obtained by a physician. CEO or designee will review all individuals' annual physical coming in to the program to ensure all required information is present. (AS 4/20/15)] 01/06/2015 Implemented
2380.181(e)(5)Individual #2's assessment, dated 11/27/14, did not indicate the individual's ability to self-administer medication; Individual #3's assessment, dated 10/27/14, did not indicate the individual's ability to self-administer medication; Individual #4's assessment, dated 6/30/14, did not indicate the individual's ability to self-administer medication; Individual #5's assessment, dated 12/02/14, did not indicate the individual's ability to self-administer medication.The assessment must include the following information: The individual¿s ability to self-administer medications.The self-administering medication portion of the assessment had only been complted for those receiving medications at the ATF. Beginning immediately after inspection it is now done with everyone. Information is gathered from the team for this section if the individual does not take medications at the ATF. A training was completed with Program Specialists. 01/06/2015 Implemented
2380.181(f)Individual #1's assessment was dated for 7/09/14, and was sent to the team on 7/09/14 for an ISP meeting held on 7/31/14.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).All dates for assessments were cross compared with ISP dates to ensure the minimum 30 days were in place for submission to the SC and team, and any changes needing made were made. A training was completed on the regulation. 01/06/2015 Implemented
2380.186(d)Individual #2's ISP three month review documentation was not sent to the supports coordinator from 3/12/13 until 12/02/14.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.Training was completed with all Program Specialists, and those responsible for distribution of ISP reviews/3 month reviews regarding the timelines for submission to SC's. Starting with the vey next ISP review the Program Specialists ensured this was documented. It had been occurring but dates were not being written. This is now ensured. 01/06/2015 Implemented
SIN-00261671 Renewal 03/04/2025 Compliant - Finalized
SIN-00204010 Renewal 04/19/2022 Compliant - Finalized
SIN-00186802 Renewal 04/27/2021 Compliant - Finalized
SIN-00168332 Renewal 12/27/2019 Compliant - Finalized
SIN-00127863 Renewal 01/05/2018 Compliant - Finalized
SIN-00054359 Renewal 01/08/2014 Compliant - Finalized
SIN-00041212 Renewal 09/25/2012 Compliant - Finalized