Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286694 Renewal 04/09/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)Fire drills were conducted at the facility on 2/24/2025 and again on 5/27/2025; a difference of 92 days. Fire drills were conducted at the facility on 5/27/2025 and again on 8/28/2025; a difference of 93 days.A fire drill shall be held at least every 90 calendar days. A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.We have assigned this role to a different staff. We have also created an electronic calendar with a reminder system based on a shorter span of time than required. This will ensure that Lark remains compliant on the 90-day regulation for 2390. 04/17/2026 Implemented
2390.151(e)(4)Individual #2's assessment, completed by Program Specialist #1 on 8/12/2025, did not include an assessment of the individual's supervision needs while in the community. This section of the assessment was left blank. Individual #2's support plan, last updated 9/10/2025, indicates that they have services authorized for the agency to support them at a 1:2 or 1:3 staff-to-client ratio while participating in community-based activities. [Repeated violation: 4/16/2025] The assessment must include the following information: The client's need for supervision.Program Specialists will be retrained on the completion of the assessment form. Training will encompass the following areas: all questions or assessment areas must be answered no matter the determination of the applicability to the individual being assessed. If an area is determined not to be applicable, then a statement must be written to describe why it was determined that the assessed area did not apply to this individual. Reflection on the future applicability must be addressed and contained within the assessment form. 04/17/2026 Implemented
2390.151(e)(5)Individual #2's assessment, completed by Program Specialist #1 on 8/12/2025, did not include an assessment of the individual's ability to self-administer medications. This section of the assessment was left blank. The assessment must include the following information: The client's ability to self-administer medications.Program Specialists will be retrained on the completion of the assessment form. Training will encompass the following areas: all questions or assessment areas must be answered no matter the determination of the applicability to the individual being assessed. If an area is determined not to be applicable, then a statement must be written to describe why it was determined that the assessed area was not applicable to this individual. Reflection on the future applicability must be addressed and contained within the assessment form. 04/17/2026 Implemented
2390.151(e)(6)Individual #2's assessment, completed by Program Specialist #1 on 8/12/2025, did not include an assessment of the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. This section of the assessment was left blank. The assessment must include the following information: The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Program Specialists will be retrained on the completion of the assessment form. Training will encompass the following areas: all questions or assessment areas must be answered no matter the determination of the applicability to the individual being assessed. If an area is determined not to be applicable, then a statement must be written to describe why it was determined that the assessed area did not apply to this individual. Reflection on the future applicability must be addressed and contained within the assessment form. 04/17/2026 Implemented
2390.151(e)(7)ndividual #2's assessment, completed by Program Specialist #1 on 8/12/2025, did not include an assessment of the individual's knowledge of the danger of heat sources and their ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. This section of the assessment was left blank.The assessment must include the following information: The client'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.Program Specialists will be retrained on the completion of the assessment form. Training will encompass the following areas: all questions or assessment areas must be answered no matter the determination of the applicability to the individual being assessed. If an area is determined not to be applicable, then a statement must be written to describe why it was determined that the assessed area did not apply to this individual. Reflection on the future applicability must be addressed and contained within the assessment form. 04/17/2026 Implemented
2390.151(e)(8)Individual #1's assessment, completed by Program Specialist #1 on 11/5/2025, did not include an assessment of the individual's ability to evacuate in the event of a fire. This section of the assessment was left blank. Individual #2's assessment, completed by Program Specialist #1 on 8/12/2025, did not include an assessment of the individual's ability to evacuate in the event of a fire. This section of the assessment was left blank. [Repeated violation: 4/16/2025] The assessment must include the following information: The client's ability to evacuate in the event of a fire.Program Specialists will be retrained on the completion of the assessment form. Training will encompass the following areas: all questions or assessment areas must be answered no matter the determination of the applicability to the individual being assessed. If an area is determined not to be applicable, then a statement must be written to describe why it was determined that the assessed area did not apply to this individual. Reflection on the future applicability must be addressed and contained within the assessment form. 04/17/2026 Implemented
2390.18(i)Enterprise Incident Management incident #9780721 had a discovery date of 1/26/2026 at 12:00am and a due date for the incident to be finalized of 12:00am on 2/25/2026; however, as of 11:00am on 4/9/2026, the incident had not been finalized through the Department's information management system. Enterprise Incident Management incident #9780728 had a discovery date of 1/27/2026 at 12:00am and a due date for the incident to be finalized of 12:00am on 2/26/2026; however, as of 11:00am on 4/9/2026, the incident had not been finalized through the Department's information management system.The facility shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the facility notifies the Department in writing that an extension is necessary and the reason for the extension.A misunderstanding on the part of the facility to the inclusion of weather events into IM had occurred. Our AE brought this to our attention, so we documented the closure in IM. However, we did not complete the process. As such, we have retrained staff responsible for entering this data into the IM system on the completion of the process. 04/17/2026 Implemented
2390.152(c)Individual #3's assessment, completed by Program Specialist #1 on 12/12/2025, stated the individual was a skill level "3", indicating the individual could independently sense and move away from heat sources which exceed 120°F; however, Individual #3's support plan, last updated 4/6/2026, did not include a description of the type of assistance Individual #3 would require in order to remain safe around uninsulated heat sources. Individual #3's assessment, completed by Program Specialist #1 on 12/12/2025, stated the individual requires a 1:6 staff-to-client ratio while receiving supports in the facility and is required to check in with their job coach before leaving the work floor. The assessment also indicated that Individual #3 requires supervision to stay on task and, in regard to community supervision, Individual #3 may need occasional reminders to pay attention to their surroundings if they are working outside of the facility. Individual #3's support plan, last updated 4/6/2026, only stated that the individual receives 6.5 hours of supervision two days per week at the facility; however, it provided no additional information regarding the type of supervision Individual #3 needs in order to stay safe in the facility and community. Individual #3's support plan has not been updated based upon the current assessment.The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment.The individual plan shall accurately reflect the determinations as found in the assessment of the individual. The program specialist shall ensure that the ISP accurately reflects those determinations. If there is a discrepancy between what the program specialist determined should be in the ISP, the program specialist shall return the document to the support coordinator with a request to make the determined corrections. This shall be done through email. If the support coordinator does not make the changes, then the program specialist will print the email chain and add it to the client's record. 04/17/2026 Implemented
2390.18(a)(11)Enterprise Incident Management incident #9780721 had a discovery date of 1/26/2026 at 12:00am; however, the Incident First Section was not initially reported through the Department's information management system until 2:44pm on 2/4/2026. Enterprise Incident Management incident #9780728 had a discovery date of 1/27/2026 at 12:00am; however, the Incident First Section was not initially reported through the Department's information management system until 2:50pm on 2/4/2026.The facility shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Emergency ClosureTraining on the use of the IM system for weather-related incidents will be tracked through our tracking system. This information will be shared with the Director of Administrative Services and the CEO within 24 hours after the weather-related incident. Either of those individuals will check on the accuracy of the entered data. 04/17/2026 Implemented
SIN-00264628 Renewal 04/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(d)Individual #1, date of admission 10/29/2024, had their initial assessment completed on 12/27/2024. This assessment was not signed or dated by Program Specialist #1.The program specialist shall sign and date the assessment.A tracking spreadsheet for CPS individuals containing all necessary information has been established to meet all regulatory compliance. The Administrative team will ensure that all signatures and dates are in compliance with regulations. Administrative staff and Program Specialists have been trained on the utilization of the tracking spreadsheet. 04/24/2025 Implemented
2390.151(e)(2)Individual #1, date of admission 10/29/2024, had their initial assessment completed on 12/27/2024. This assessment did not include the likes, dislikes and interest of client, including vocational and employment interests of the client. This section of the assessment was left blank.The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client.Upon completion of the assessment the administrative staff will notify the Senior Director of Support Services of the completion. The Senior Director of Support services will review the document for completion and accuracy. She will ensure that likes, dislikes and interests of the individual, including vocational and employment interest are included. After she has reviewed the information, she will notify the administrative staff that it is ready for distribution. If the assessment, does not have the required information, the Senior Director of Support Services will return it to the Program Specialist for corrections. It will then be returned to the Senior Director of Support Services for approval once corrections are made and then forwarded to the administrative staff for distribution. 04/24/2025 Implemented
2390.151(e)(4)Individual #1, date of admission 10/29/2024, had their initial assessment completed on 12/27/2024. This assessment did not include the client's need for supervision. This section of the assessment was left blank. The assessment must include the following information: The client's need for supervision.Upon completion of the assessment the administrative staff will notify the Senior Director of Support Services of the completion. The Senior Director of Support services will review the document for completion and accuracy. They will ensure that the section regarding client's need for supervision is completed. After s/he has reviewed the information, s/he will notify the administrative staff that it is ready for distribution. If the assessment does not include the required information, the Senior Director of Support Services will return the document to the Program Specialist. Once corrections are made, the Program Specialist will return the assessment to the Senior Director of Support Services for approval. The Senior Director of Support Services will then forward to the administrative staff for distribution. 04/24/2025 Implemented
2390.151(e)(8)Individual #1, date of admission 10/29/2024, had their initial assessment completed on 12/27/2024. This assessment did not include the client's ability to evacuate in the event of a fire. This section of the assessment was left blank. The assessment must include the following information: The client's ability to evacuate in the event of a fire.Upon completion of the assessment the administrative staff will notify the Senior Director of Support Services of the completion. The Senior Director of Support Services will review the document for completion and accuracy. They will ensure that the section regarding client's ability to evacuate in the event of fire has been completed. After s/he has reviewed the information, s/he will notify the clerical staff that it is ready for distribution. If the assessment does not include the required information, the Senior Director of Support Services will return the document to the Program Specialist. Once corrections are made, the Program Specialist will return the assessment to the Senior Director of Support Services for approval. The Senior Director of Support Services will then forward to the Clerical Staff for distribution. 04/24/2024 Implemented
2390.151(e)(9)Individual #1, date of admission 10/29/2024, had their initial assessment completed on 12/27/2024. This assessment did not include documentation of the client's disability, including functional and medical limitations. This section of the assessment was left blank.The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.Upon completion of the assessment the administrative staff will notify the Senior Director of Support Services of the completion. The Senior Director of Support services will review the document for completion and accuracy. They will ensure that the section regarding client's disability, including functional and medical limitations has been completed. After s/he has reviewed the information, s/he will notify the administrative staff that it is ready for distribution. If the assessment does not include the required information, the Senior Director of Support Services will return the document to the Program Specialist. Once corrections are made, the Program Specialist will return the assessment to the Senior Director of Support Services for approval. The Senior Director of Support Services will then forward to the administrative staff for distribution 04/24/2025 Implemented
SIN-00243368 Renewal 04/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1, date of admission 09/11/2023, was instructed on general fire safety and the use of fire extinguishers on 10/10/2023. Individual #2, date of admission 09/18/2023, was instructed on general fire safety and the use of fire extinguishers on 10/10/2023.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.New individual orientation processes have been redeveloped to ensure compliance with first day fire safety training. Additionally, a new individual orientation form has been developed that clearly articulates when trainings should occur with an area for recording the date of the training. Moreover, our Fire Safety Policy had been updated to include all changes made to the training schedule. 05/01/2024 Implemented
2390.112(a)Individual #1, date of admission 09/11/2023, had orientation to the facility and the services offered completed on 10/11/2023. Individual #2, date of admission 09/18/2023, had orientation to the facility and the services offered completed on 10/18/2023.Upon admission, a client shall be oriented to the facility and to the services offered. New individual orientation processes have been redeveloped to ensure compliance with first day orientation training. Additionally, a new individual orientation form has been developed that clearly articulates when trainings should occur with an area for recording the date of the training. Moreover, our Provision of Services Policy has been evaluated to ensure that the processes have been included within the policy. 05/01/2024 Implemented
2390.151(a)Individual #2, date of admission 09/18/2023, had their initial assessment completed and disseminated to the individual plan team on 11/23/2023.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Program Specialist were retrained on 55 PA Code 2390.151(a). The Provision of Services Policy was analyzed to ensure it had the correct regulatory language concerning assessment expectations. Retraining also occurred for all program specialists in compliance expectations for all new individuals. The new individual orientation paperwork including a tracking checklist was reviewed. 05/01/2024 Implemented
SIN-00206475 Renewal 06/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1 had a functional assessment completed 5/12/21, and then again on 6/08/22. Individual #2 had a functional assessment completed 02/12/21, and then again on 4/21/22.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Lark conducted the functional assessment for individual #1 on 6/08/22 and the functional assessment for individual #2 on 4/21/22 in order to ensure the functional assessments occurred. The individuals' names and dates for assessment were placed into Lark's tickler system to ensure timely compliance in 2023 and ongoing. [Trainings for Program Specialist, dated 6/23/22, were received on 7/21/22 and reviewed on 7/22/22. DPOC by HDKP, HSLS, on 7/22/22.] 06/23/2022 Implemented
2390.21(u)Individual #1 was informed of their rights on 04/30/21, and then again on 05/26/22; Individual #3 was informed of their rights on 04/30/21, and then again on 05/27/22; Individual #4 was informed of their rights on 04/30/21, and then again on 05/19/22.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Lark trained individual #1 on 5/26/22; individual #3 on 5/27/22; and individual #4 on 5/19/22 in order to ensure the training occurred for the year. The individual names and dates of training were placed into Lark's tickler system to ensure timely compliance in 2023 and ongoing. [Updated and signed Individual Rights forms for Individuals #1, #2. and #3 were received on 7/21/22 and reviewed 7/22/22. DPOC by HDKP, HSLS, on 7/22/22.] 06/23/2022 Implemented
2390.151(f)Individual #1's functional assessment was sent to the individual plan team members on 06/08/22 for an ISP meeting that had occurred on 05/26/22. Individual #2's functional assessment was sent to individual plan team members on 04/21/22 for an ISP meeting that had occurred on 04/14/22. Individual #3's functional assessment was sent to the individual plan team members on 11/02/21, prior to the completion of the assessment which occurred on 11/03/21.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.The new program specialist has been retrained on the regulatory expectations of the timelines for assessments. Furthermore, the program specialist has been retrained on the need to have the assessments to the individual's plan team members at least 30 calendar days prior to the individual's meeting. The program specialist has been trained on the concepts of the tickler system. [Trainings for Program Specialist, dated 6/23/22, were received on 7/21/22 and reviewed on 7/22/22. DPOC by HDKP, HSLS, on 7/22/22.] 06/23/2022 Implemented
SIN-00224720 Renewal 05/18/2023 Compliant - Finalized
SIN-00189048 Renewal 06/15/2021 Compliant - Finalized
SIN-00165418 Renewal 11/01/2019 Compliant - Finalized