Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253691 Renewal 10/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(u)The most recent individual rights statements for individual One were signed greater than 1 year apart. The dates they were signed are 9/7/23 and 10/8/24The 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.On 11/21/24, rehabilitation manager, Sarah Holesworth, with the support of vocational director, Jordan Pfister, met with all personnel involved in case management to discuss and provide training on regulation 2380.21(u) related to individuals¿ rights. (See attachment 1, 2, 3, and 4). It was explained that the term ¿annual¿ directly means 365 days, not calendar year. Therefore, BARC shall inform and explain individual rights and the process to report any rights violations to the individual, and persons designated by the individual, upon admission and annually thereafter, within a rolling 365 calendar days of the previous year¿s explanation of rights. 11/21/2024 Implemented
2380.181(f)Annual Assessment for individual One was sent to the team on 9/3/24 and her ISP meeting occurred on 9/26/24. The annual assessment was sent to the team less than 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.On 11/21/24, rehabilitation manager, Sarah Holesworth, with the support of vocational director, Jordan Pfister, met with all personnel involved in case management to discuss and provide training on regulation 2380.181(f) related to timely submission of assessment documentation prior to team meetings. (See attachment 1, 2, 3, and 4). It was explained that the expectation is to submit annual assessment materials to the individual planning team members at least 30 calendar days prior to the individual plan meeting. It was further explained that if an outside team member recommends pulling a meeting together too soon, within the 30-day window, it is BARC¿s expectation our case managers object to the rushed date and recommend later dates to ensure regulatory compliance is followed for all personnel to fully review all documents submitted. 11/21/2024 Implemented
SIN-00213271 Renewal 10/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The soap being used in the bathrooms were brands Gojo and Excelon. Both of these brands contain active chemicals in them with instructions to contact poison control if ingested. All of the soap were replaced with soaps that do not contain active chemicals prior to the conclusion of the inspection.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All of the Excelon and GoJo soaps were removed during inspection and replaced with Soft Soap which does not contain active chemicals and does not have the warning (Attachment #1) 10/21/2022 Implemented
2380.70(d)The first aid kit did not contain antiseptic. Antiseptic was placed in the kit before the conclusion of the inspection.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.Antiseptic (Hydrogen Peroxide) was placed in the First Aid Kit during Inspection (Attachment #3). 10/21/2022 Implemented
SIN-00161527 Renewal 07/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The Hot water temperature in the cafeteria single use bathroom sink was 132.1 degrees Fahrenheit.Hot water temperatures in areas accessible to individuals may not exceed 120°F.The mixing valve to the sink was adjusted and monitored. Temperatures were taken for three days (9-16, 9-17, 9-18) at three intervals daily. Temperatures remained below 120 degrees Fahrenheit at all times. As part of the monthly safety inspection, all sink water temperatures will continue to be tested and addressed as necessary. 09/18/2019 Implemented
2380.69(e)The trash receptacle in the bathroom of the cafeteria was not covered.Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.A new trashcan which has a lid was purchased and placed in the restroom. 08/02/2019 Implemented
2380.70(a)There was no first aid area separated by a partition or privacy screen from program areas. There also was no designated cot or bed for first aid area.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.A permanent first aid area partition has been installed. The fully reclining chair, blanket, and pillow will remain in this area. 09/19/2019 Implemented
2380.111(c)(5)There was no record of Tuberculin test for Individual #1 since admission into program on 7/2/18.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.The program specialists will ensure that documentation of the tuberculin test with negative results is filled out by the physician. If that information is not filled out upon receipt of the physical, the program specialist will notify the team and send a written request for the information to be filled out to the physician's office. The program specialist will submit the request on a monthly basis until the information is received and satisfies our regulations. A copy of the written requests for documentation will be kept in the individual's file. A notice referring to the need for complete physicals is being attached to all paychecks for the individuals in the 2380 program and sent out on 9-20-19. An initial written request for a complete physical was mailed to the physician office for Individual #1 on 9-6-19. This regulation requirement was reviewed with all of the program specialists on 9-19-19. 09/19/2019 Implemented
2380.111(c)(10)Individual #1's physical exam dated 9/18/18 did not include Information pertinent to diagnosis in case of an emergency it was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The program specialists will ensure that information pertinent to the diagnosis is filled out by the physician. If that information is not filled out upon receipt of the physical, the program specialist will notify the team and send a written request for the information to be filled out to the physician's office. The program specialist will submit the request on a monthly basis until the information is received and satisfies our regulations. A copy of the written requests for documentation will be kept in the individual's file. A notice referring to the need for complete physicals is being attached to all paychecks for the individuals in the 2380 program and sent out on 9-20-19. An initial written request for a complete physical was mailed to the physician office for Individual #1 on 9-6-19. This regulation requirement was reviewed with all program specialists on 9-19-19. 09/19/2019 Implemented
SIN-00090683 Renewal 01/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's previous physical was dated 12/2/14 and the most recent physical was 12/21/15.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.A spread sheet with annual physical due dates was developed and will be updated annually by the rehabilitation manager. Two months prior to the annual physical due date, a letter will be sent to the residential provider to remind them of the physical date. A letter was written by the rehabilitation manager and sent to all individuals' responsible parties to ensure they are aware of the need for a physical to occur within 365 days of the previous physical. The letter also states that failure to comply with this regulation might result in suspension or termination from the ATF program. A copy of this letter will be included with the plan of correction. When the next physical is completed for an individual in the ATF, that physical will be scanned to the Regional Licensing administrator as part of the plan of correction to document that the physical was held within 365 days of the last one. In addition, when Individual #1's physical is completed in December, that physical will be scanned to the Regional Licensing administrator as part of the plan of correction. 06/23/2016 Implemented
2380.111(c)(6)Individual #2's physical dated 6/10/15 did not document that he was free of communicable diseases.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.A letter was written by the rehabilitation manager and sent to all individuals' responsible parties to ensure they are aware of the need for every line of the physical to be filled out. The letter also states that failure to comply with this regulation might result in suspension or termination from the ATF program. A copy of this letter will be included with the plan of correction. When the next physical is completed in June for Individual #2 that physical will be scanned to the Regional Licensing administrator as part of the plan of correction to document that the physical was filled out completely. 06/23/2016 Implemented
2380.111(c)(11)Individual # 1's physical dated 12/21/15 did not include special instructions for the individuals diet.The physical examination shall include: Special instructions for an individual's diet.A letter was written by the rehabilitation manager and sent to all individuals' responsible parties to ensure they are aware of the need for every line of the physical to be filled out. The letter also states that failure to comply with this regulation might result in suspension or termination from the ATF program. A copy of this letter will be included with the plan of correction. When the next physical is completed in December for Individual #2 that physical will be scanned to the Regional Licensing administrator as part of the plan of correction to document that the physical was filled out completely. In addition, when the next physical is completed for an individual in the ATF, that physical will be scanned to the Regional Licensing administrator as part of the plan of correction to document that the physical was filled out completely. 06/23/2016 Implemented
2380.173(1)(i)Individual # 1's record did not describe any identifying marks.Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.Training was completed on 5-31-16 with the rehabilitation manager and the ATF program specialist to ensure their understanding of this regulation. The corrected personal information sheet for individual #1 will be included with the plan of correction as documentation. A second corrected personal information sheet will also be included. The next time there is a new admission for the ATF program, the completed personal information sheet will be scanned to the Regional Licensing administrator as part of the plan of correction. 06/02/2016 Implemented
2380.181(e)(13)(v)Individual # 1's assessment of 8/9/15 did not include progress and growth in the area of 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.Training was completed on 5-31-16 and 6-2-16 with the rehabilitation manager and the ATF program specialist to ensure their understanding of this regulation. An audit of 1 assessment per month will be completed by the rehab manager to ensure compliance with this regulation. The corrected assessment for individual #1 will be included with the plan of correction as documentation. When the next assessment for a client in the ATF program is completed (due by 6-29-15), that assessment will be scanned to the Regional Licensing administrator as part of the plan of correction. 06/02/2016 Implemented
SIN-00066801 Renewal 10/02/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)Individual #1's physical examination, dated 7/14/14, did not include assessment of health maintenance needs and the need for blood work. Individual #2's physical examination, dated 6/6/14, did not include assessment of health maintenance needs and the need for blood work. 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 physicals for the two consumers currently attending the program have been mailed to their respective physicians, including a cover letter explaining this information must be included on the physical. The physician is also asked to sign and date the physical once this information has been updated. When received from the physician, the Rehabilitation Manager will review for accuracy. The physical will then be scanned and emailed to verify compliance with this regulation. (If information is still missing, the physician will be contacted by phone and advised of what needs to be completed and the form will then be mailed to the physician for completion.) The Rehabilitation Manager will review the completed physicals for all new referrals to the program prior to their admission. If the physical does not contain this information, it will be returned to the physician with a cover letter indicating what needs to be updated. The individual will not be admitted to the program until the Rehabitation Manager receives the updated physical and verifies it is fully completed. 10/26/2014 Implemented
2380.111(c)(8)Individual #2's physical examination, dated 6/6/14, did not include the physical limitations.The physical examination shall include: Physical limitations of the individual.The Program Specialist for the two consumers currently in the program have mailed their physicals to their physician with a cover letter requesting their physical limitations be listed on the physical, signed and dated by the physician, and returned. Once received, the Rehabilitation Manager will ensure the physical limitations are listed, and the physician signed and dated the physical. The physicals will then be scanned and emailed to verify this has occurred. The Rehabilitation Manager will review the physicals for all new referrals to the program and ensure they are complete. If not, the physicals will be mailed to the individual's physician with a cover letter requesting completion and the physician then sign and date the physical. Once received from the physician, the Rehabilitation Manager will review the physical to ensure it is complete. The individual will not be admitted until a complete physical is received and accuracy is verified. 10/26/2014 Implemented
2380.111(c)(9)Individual #1's physical examination, dated 7/14/14, did not include contradictions to medications. The physical examination shall include: Allergies or contraindicated medication.The physicals for the two consumers in the program have been sent to their physicians with a cover letter explaining the physical did not include contradictions to medications. The physician was asked to answer this question and include the date the question was answered. Once the updated phsycial is received and reviewed for completeness, the physical will be scanned and emailed to verify compliance with this regulation. For all new admissions to the program, the Program Specialist will ensure the physical is fully completed. If not, the physical will be returned to the individual's physician for completion, including a cover letter indicating what needs to be completed. The individual will not be admitted to the program until a complete physical is received and reviewed for accuracy. The Rehabilitation Manager will ensure the physicals for the two consumers currently in the program are fully completed, dated, and signed by the individual's physician. The Rehabilitation Manager will review the physicals for all individuals accepted into the program, prior to their admission to the program, to ensure their physicals are fully completed. 10/26/2014 Implemented
SIN-00111001 Renewal 03/29/2017 Compliant - Finalized