Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257512 Renewal 11/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The program has an extended evacuation time of 5 minutes, however the letter that designates this is applicable for 1 year. The letters designating the extended evacuation time are dated September 25 2023 and November 12 2024. The fire drill that occurred on October 25, 2024 is not covered by these letters.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.A line item was added on the Monthly Safety Hazard Inspection form for the Bentley Center, which is the building where the 2380 program is located (see Attachment #2, Page 2). This line item states: ¿annual letter indicating period of the time allowed for evacuation¿. There is a column on that form for comments. The chairperson of the Safety Committee (who is also the Director of the ADLC) is the person that does the monthly safety inspection of the buildings. Every month they will indicate the date of the last annual letter we have to indicate this period of time allowed for evacuation. They will indicate this date under the comment section. Once this date is within two months of the annual due date, the Adult Daily Living Center Director will contact the Caln Township Fire Safety Expert. That allows two months to schedule a fire drill that this fire safety expert can observe and then write a letter indicating the period allowed for evacuation. 02/14/2025 Implemented
2380.21(u)Individual Rights need to be signed on an annual basis however the only one on record for individual #1 -- Current is 11/22/24The 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.The Client Files Checklist was revised (See Attachment #1). This checklist now indicates that the Client Rights Policy needs to be signed annually (see Page 1). On the admission day into the ADLC the assigned program specialist will have the individual sign the Client Rights form. Going forward the client will again sign the Client Rights form the day that their ISP is scheduled. If a client has a legal guardian, the guardian would sign the form at the ISP meeting. This checklist will be used and completed by the program specialist when a new client is admitted to assist the program specialist with completing all the necessary forms. After the Initial Assessment is done more of the checklist will be completed, and then again, the program specialist will use the checklist when preparing for the individual¿s ISP meeting. Going forward the individual will sign the Client Rights form at their ISP meeting to ensure that it is signed annually. 02/18/2025 Implemented
SIN-00235099 Renewal 11/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(a)The first aid area is not separated by a partition or privacy screen.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.A privacy screen was added to the first aid area (See Attachment #8). 01/10/2024 Implemented
2380.70(b)The first aid area did not contain a pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.A pillow was added to the first aid area (See Attachment #9) 01/10/2024 Implemented
2380.111(a)The Annual Physical Examination for Individual #1 was not completed annually, the previous physical was completed 12/20/2021 and not completed again until 01/05/2023.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.With all due respect, concerning Individual #1¿s annual physical examination, the Program Specialist did email a reminder to Individual #1¿s residential provider (see Attachment #1) reminding them that Individual #1¿s physical was needed to be completed by 12/20/22. When this was discussed with the licensing inspector at the exit interview on November 30, 2023, he indicated that we could email this documentation to him. This documentation was emailed to the licensing inspector the following day, December 1, 2023 (See Attachment #2). Individual #1 had a physical exam on 12/20/21 (See Attachment #3). This is the front page of the exam to indicate the date that the exam was completed. Attachment #4 is the front page of the physical exam completed on 1/5/23. The exam was late, but the residential provider had been reminded via an email when Individual #1¿s physical was due. The residential provider did respond to the email indicating that they had issues scheduling the appointment (See Attachment #1). 01/08/2024 Implemented
2380.111(c)(5)Tuberculin (TB) skin testing with negative results was not completed every 2 years. The last test was administered to individual #1 on 10/25/2021.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.With all due respect, the documentation for Individual #1¿s TB test was in his file. Handi-Crafters was told by the licensing inspector at the exit interview that the documentation could be emailed to him. This documentation was emailed to the licensing inspector on December 1, 2023 (See Attachment #2). This email included attachments documenting Individual #1¿s last two TB tests. On the front page of Individual #1¿s 12/20/21 annual physical exam it indicates that he received a TB test on 10/25/21, read on 10/27/21, and it was negative (See Attachment #3). Attachment #5 indicates that Individual #1 received another TB test on 10/10/23, read on 10/12/23, and it was negative. The second TB test is less than 2 years after the first TB test. Both of these documentations were in Individual #1¿s file on November 30, 2023, and sent to the licensing inspector via email on 12/1/23. 01/08/2024 Implemented
SIN-00215351 Renewal 11/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #2, activities aide hired 11/9/21 did not receive a criminal history check until 8/9/22. Staff #3, CNA hired 3/1/22 did not receive a criminal history check until 8/9/22. Staff #4, activities aide hired 7/26/21 did not receive a criminal history check until 11/26/22. Staff #5, activities aide hired 11/22/21 did not receive a criminal history check until 11/26/22.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Handi-Crafters will not allow hired staff to start employment until a Criminal History Check is received on that prospective employee. 01/24/2023 Implemented
2380.58(b)There was standing water located in the warehouse and the dining hall where individuals were eating.Floors, walls, ceilings and other surfaces shall be free of hazards.See attached invoice for repair of the roof above both the dining hall and the warehouse (Attachment #10). 01/18/2023 Implemented
2380.67(a)A lounge chair in the program room is ripped and should be replaced.Furniture and equipment shall be nonhazardous, clean and sturdy.The lounge chair that was damaged was removed and put into the dumpster. Another chair was purchased and put into the same location. (See Attachment #6) 01/18/2023 Implemented
2380.111(c)(5)Individual #1, 3/16/22 physical examination does not address their tuberculosis test, it only states to see immunization records attached and what is attached is a screen shot of a paper which lists tuberculosis results without any identifying information to show that these results belong to individual #1.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.See Attachment #8 which is a copy of Individual #1¿s TB test. It indicates that the TB test was placed on 5/23/22,and read on 5/25/22. It also indicates that it was a negative test. This documentation is from PentaHealth Colonial Family Practice, and has Individual #1¿s name on the bottom left corner. 01/25/2023 Implemented
2380.39(c)(6)Staff #1, activities coordinator did not have training in the implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff #1 and all program staff were trained by the Director in the Implementation of the individual plan. The training included a review of the parts of the individual plan that are especially important for staff that work directly with individuals. These sections of the plan included: ¿Like & Admire¿, ¿Know & Do¿, ¿Desired Activities¿, ¿Important To¿, and ¿What Makes Sense¿. Also included was medical information, Health and Safety, and the Outcomes Section. This training was completed on 1/25/23. (See Attachment #2 for the training sign in sheet.) 01/25/2023 Implemented
2380.181(f)Individual #2 did not have their assessment sent to the plan team at least 3o days prior to 1/14/22 individual plan 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.Please see the attached email that was sent to Individual #2¿s team on December 1, 2022 attaching Individual #2¿s annual assessment (See Attachment #4). Also attached is the invitation to the ISP meeting noting that Individual #2¿s ISP meeting was on January 9, 2023 (See Attachment #5). This assessment was sent to the team more than 30 days before the ISP meeting. 01/25/2023 Implemented