Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263094 Renewal 03/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(14)Individual #1's assessment, completed 7/9/2024, did not include the individual's ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.The Executive Director issued the following memo to the Community Participation Support Programs Director and the Transition Services Program Specialist on Thursday, March 27, 2025: This memo is in regard to maintaining compliance with regulations pertaining to the completion of required documentation and maintaining compliance with regulation 2380.181(e)(14) pertaining to the completion of an individual's assessment; specifically, the individual's knowledge of water safety and ability to swim. Attached is ICW's orientation checklist and ISP checklist. The following retraining pertains to the completion of the orientation checklist upon admission and the completion of the ISP checklist that is used before, during, and after the ISP process: Checklist items can never be marked as complete until all information needed is obtained and documented. Program Specialists are responsible for the completion of all items and Program Directors are responsible to review all marked items for completeness prior to the filing of either checklist. If information is not included in the most current ISP or is not readily available to complete the required documentation; as per any chapter's regulations, the individual's supports coordinator and/or supports coordinator's supervisor should be contacted to obtained information that can only be obtained by or from the supports coordinator or supports coordinator's supervisor and contact the individual (Parent/ Guardian/Caregiver/Residential Provider) directly to obtain any other information. Always document the name of the person contacted and the date the information was obtained. This will ensure that all documentation is completed as required in a timely manner. To specifically address the noncompliance sited during the Monday, March 24, 2025, inspection; the orientation checklist should have remained incomplete until information missing from the current ISP pertaining to the individual's knowledge of water safety and ability to swim was obtained from the supports coordinator or individual. Then, the knowledge of water safety and ability to swim section of the assessment should have been completed with the information obtained along with the name of person contacted and the date the information was obtained. The orientation checklist and initial assessment specific to this noncompliance was reviewed. The date on the assessment indicated the assessment was on the first day of programming; keep in mind, an initial assessment is due 60 calendar days after admission in order to allow amble time to gather all required information. 03/27/2025 Implemented
SIN-00223156 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(b)Direct Service Worker #1, date of hire 9/7/2022, is not a permanent resident of Pennsylvania. An application for a Federal Bureau of Investigation criminal history record check was not submitted to the Pennsylvania Department of Aging within five working days of the employee's date of hire.If a prospective employe who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.[Executive Director] contacted the Department of Aging, Protective Services Criminal History Background Check Unit on Thursday, April 20, 2023, to setup a facility code on the IdentoGo website for ICW and to establish the correct service code under OAPSA to be used, if a prospective employee who will have direct contact with individuals is not and, for the two years immediately preceding the date of application, has not been a resident of this Commonwealth. After multiple emails, the Department of Aging, Protective Services Criminal History Background Check Unit sent ICW¿s facility ID Code to IdentoGo on Friday, April 21, 2023. The facility ID Code will be available to use on the IdentoGo website starting the next business day (which will be Monday, April 24, 2023). The email also contained a service code that will be used by all applicable prospective employees when scheduling the required in-person appointment to obtain a Federal Bureau of Investigation (FBI) Criminal History Record Check. A memo from [Executive Director] to Fiscal Director/Associate Executive Director and Assistant Director regarding ICW¿s service code to be used by all applicable prospective employees when scheduling the required in-person appointment to obtain the proper Federal Bureau of Investigation (FBI) Criminal History Record Check was issued and discussed on Monday, May 1, 2023. A copy of the email the Department of Aging, Protective Services Criminal History Background Check Unit will be sent via email for your review. 05/01/2023 Implemented
2380.53(b)At 2:15PM an unlabled spray bottle of a blue liquid was in a locked cabinet in the bathroom.Poisonous materials shall be stored in their original, labeled containers.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.53(b): All chemicals not in their original, labeled container were removed from the locked cabinet located in the restroom area and disposed of properly on April 20, 2023, the [Transitional Services Director] by [Executive Director] made revisions to ICW¿s Steps to Success monthly safety inspection checklist on Tuesday, April 25, 2023; specifically, Inspection item: Are chemicals in a locked cabinet? The words ¿in their original, labeled containers¿ were added. A memo from [Executive Director] to [Transition Service Director] regarding poisons and a copy of the newly revised monthly safety inspection checklist was issued on Tuesday, April 25, 2023. [Executive Director] and [Transition Service Director] discussed the revisions made to ICW¿s Steps to Success monthly safety inspection checklist on Tuesday, April 25, 2023; specifically, the Inspection item: Are chemicals (in their original, labeled containers) in a locked cabinet? Also, a memo from [Transition Service Director] to ICW Steps to Success program staff regarding poisons and on-going compliance with the chapter 2380 regulation pertaining to poisons was issued on Monday, May 1, 2023. A copy of the revised monthly safety inspection checklist will be sent via email for your review. 05/01/2023 Implemented
2380.64(a)At 2:28PM, the handrail, along the interior ramp and three stairs at the exit in the rear of the facility, is loose and wobbles back and forth when in use.Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.64(a): [Transition Service Director] contacted Prudential Realty Company and informed them of a handrail that needed fixed in the area used by ICW Steps to Success as a second emergency exit at location (24 South 6th Street) on Thursday, April 20, 2023. (Maintenance Supervisor) from Prudential Realty Company, informed [Transition Service Director] that a new handrail would be installed on Friday, April 21, 2023. (Maintenance Supervisor) removed the unsecured handrail and installed a brand-new, safe and secure railing on Friday, April 21, 2023. A memo from [Executive Director] to [Transition Service Director] regarding handrails and railings and a newly revised monthly safety inspection checklist was issued on Tuesday, April 25, 2023. [Executive Director] and [Transition Service Director] discussed the revisions made to ICW¿s Steps to Success monthly safety inspection checklist on Tuesday, April 25, 2023; specifically, Inspection item: Are handrails well-secured? the words ¿main program area and second exit¿ were added to maintain compliance with regulation 2380.64. A copy of the monthly safety inspection checklist, correspondence from Prudential Realty Company, and a picture of new handrail that was installed will be sent via email for your review. 04/25/2023 Implemented
2380.91(a)Individual #3 was instructed in fire safety on 6/18/2021 and then again on 7/8/2022.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.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.91: A memo to [Transition Service Director] and Erica Aikens from [Executive Director] regarding instruction upon initial admission and reinstruction annually in the areas of general fire safety, 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 was issued on Wednesday, May 3, 2023.[Executive Director] , [Transition Service Director] , and [Program Specialist] discussed the memo and reviewed the newly implemented Individual Record monthly review form; specifically, the Individual(s) not present and/or required documentation not completed form that was implemented on March 21, 2023. Further explanation of the above-mentioned Indvidual Record monthly review form and Individual(s) not present and/or required documentation not completed form content: ICW completed the transfer from a paper individual record system to an electronic record system in March 2023. At a meeting held on March 21, 2023, all staff responsible for case management were issued an Individual Record Binder that contains two sections; a not completed section and a completed section. The binder will be reviewed monthly by a supervisor for compliance with Chapter 6100, Chapter 2380, and Chapter 2390 regulations. ICW implemented the following review form: ICW Vocational Services, Inc. Individual Record Review Month ____________ Name of Reviewer ______________________________ Not Completed Section Review and discuss entire section. Completed Section Orientation Checklist ¿ Review Individual Record in E-System. ¿ Use the Individual Record master list to ensure all documents are completed, named, and scanned in correctly. ¿ Highlight all documents on the Individual Record master list that have been reviewed. ¿ Scan the Orientation Checklist into E-System. ¿ File the highlighted Individual Record master list in the completed section. ISP Checklist ¿ Review Individual Record in E-System. ¿ Use the ISP Checklist to ensure all documents are completed, named, and scanned in correctly. ¿ Highlight all documents on the ISP Checklist that have been reviewed. ¿ File the highlighted ISP Checklist in the completed section. Individual(s) not present and/or required documentation not completed form. ¿ Review Individual Record in E-System. ¿ Use the Individual(s) not present and/or required documentation not completed form to ensure all documents are completed, named, and scanned in correctly. ¿ Highlight all documents on the Individual(s) not present and/or required documentation not completed form that have been reviewed. ¿ File the highlighted Individual(s) not present and/or required documentation not completed form in the completed section. Person(s) Responsible for Individual Record Review: Executive Director Division Director ¿ Job Developer, In-Home and Community Support, 2390 Program, and 2380 Program Division Director ¿ 2390 Program Specialist(s) ¿ 2390 Division Director ¿ 2380 Program Specialist(s) ¿ 2380 ICW also implemented an Individuals(s) not present and/or required documentation not completed form to be used when an individual or individuals are absent the day of a group activity such as the annual handbook review, completion of current year W-4, or annual fire safety training that will be reviewed monthly for compliance. 05/03/2023 Implemented
2380.111(c)(3)Individual #1's most recent Tetanus immunization was on 7/19/2012. Individual #2 does not have a Tetanus immunization.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.111: A memo to [Transition Service Director] and [Program Specialist] from [Executive Director] regarding individual physical examinations and cover letters that will accompany the individual physical examination form was issued on Tuesday, May 2, 2023. [Executive Dirctor], [Transition Service Director] , and [Program Specialist] discussed the implementation of the individual physical examination cover letters on May 2, 2023. As of May 2, 2023, cover letters pertaining to the completion of the individual physical examination form to ensure updates are made to the immunization section were implemented, a procedure pertaining to the review of the returned individual physical examination form for completeness was implemented by [Executive Director], and a procedure pertaining to documentation of all attempts made when contacting physician offices when an individual physical examination form is received and not completed in its entirety was implemented by [Executive Director]. 05/02/2023 Implemented
2380.111(c)(8)Individual #3's physical examination, completed 9/26/2022, did not include physical limitations of the individual. This section was left blank. [Repeat Violation, 5/10/2022]The physical examination shall include: Physical limitations of the individual.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.111: A memo to [Transitional Services Director]and [Program Specialist] regarding individual physical examinations and cover letters that will accompany the individual physical examination form was issued on Tuesday, May 2, 2023, by [Executive Director. [Executive Director], [Transitional Services Director], and [Program Specialist] discussed the implementation of the individual physical examination cover letters on May 2, 2023. As of May 2, 2023, cover letters pertaining to the completion of the individual physical examination form to ensure all sections are completely entirely were implemented, a procedure pertaining to the review of the returned individual physical examination form for completeness was implemented by [Executive Director], and a procedure pertaining to documentation of all attempts made when contacting physician offices when an individual physical examination form is received and not completed in its entirety was implemented by [Executive Director]. 05/02/2023 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 2/1/2023, does not include medical information pertinent to diagnosis and treatment in case of emergency. This section was left blank. [Repeat Violation, 5/10/2022]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.111: A memo to [Transition Service Director] and regarding individual physical examinations and cover letters that will accompany the individual physical examination form was issued on Tuesday, May 2, 2023, by [Executive Director]. [Executive Director], [Transition Service Director] , and [Program Specialist] discussed the implementation of the individual physical examination cover letters on May 2, 2023. As of May 2, 2023, cover letters pertaining to the completion of the individual physical examination form to ensure all sections are completely entirely were implemented, a procedure pertaining to the review of the returned individual physical examination form for completeness was implemented by [Executive Director], and a procedure pertaining to documentation of all attempts made when contacting physician offices when an individual physical examination form is received and not completed in its entirety was implemented by [Executive Director]. 05/02/2023 Implemented
SIN-00204772 Renewal 05/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(8)Individual #1's physical examination completed 7/9/21, did not include physical limitations of the individual. This section was left blank.The physical examination shall include: Physical limitations of the individual.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.111: As of May 11,2022, a cover letter pertaining to the completion of the individual physical examination form was implemented, a procedure pertaining to the review of the individual physical examination form for completeness before filing the form in the individual¿s binder was discussed, and a procedure pertaining to documentation of all attempts made when contacting physician offices when an individual physical examination form is received and not completed in its entirety. TRAINING: Attached please see the memo with signature confirming the receipt and understanding of the memo. 05/11/2022 Implemented
2380.111(c)(10)Individual #1's physical examination completed 7/9/21 and Individual #2's physical examination completed 11/9/21, 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.ICW implemented the following to correct the noncompliance and remain in compliance with regulation 2380.111: As of May 11,2022, a cover letter pertaining to the completion of the individual physical examination form was implemented, a procedure pertaining to the review of the individual physical examination form for completeness before filing the form in the individual¿s binder was discussed, and a procedure pertaining to documentation of all attempts made when contacting physician offices when an individual physical examination form is received and not completed in its entirety. TRAINING: Attached please see the memo with signature confirming the receipt and understanding of the memo. 05/11/2022 Implemented
2380.113(a)Direct Service Worker #3, date of hire 3/30/22, had a physical examination completed 4/14/22.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.A memo regarding hiring procedures for ICW¿s 2380 program; specifically addressing the required receipt of a newly hired temporary/casual 2380 staff¿s physical examination and tuberculin skin testing results prior the start date, was issued on Monday, May 16, 2022. Executive Director, Assistant Director, and Transition Services Director met to discuss the memo on May 16, 2022. Attached please see the memo with signatures confirming the receipt and understanding of the memo. 05/16/2022 Implemented
2380.113(c)(2)Direct Service Worker #3, date of hire 3/30/22, had a Tuberculin skin testing with negative results completed 4/12/22.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.A memo regarding hiring procedures for ICW¿s 2380 program; specifically addressing the required receipt of a newly hired temporary/casual 2380 staff¿s physical examination and tuberculin skin testing results prior the start date, was issued on Monday, May 16, 2022. Executive Director, Assistant Director, and Transition Services Director met to discuss the memo on May 16, 2022. Attached please see the memo with signatures confirming the receipt and understanding of the memo. 05/16/2022 Implemented
SIN-00148003 Renewal 01/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1, date of admission 9/27/18, had a Tuberculin skin testing with negative results was completed 10/5/18. Individual #2 most recent Tuberculin skin testing with negative results was completed 12/21/16. [Repeated Violation-1/30/18]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.The Director of Steps to Success assisted Individual #2 contact their doctor and set up a TB test on January 10, 2019. The test was completed on January 14th; and the documentation on the negative result of the test was received on January 19th and was placed in the individual's file. A memo was written and presented to all of the staff of Steps on January 14th regarding the importance of having documentation of a negative TB test in the individual's file before the individual can start the program; as well as the necessity of each individual attending Steps having a TB test every two years. Starting January 2, 2019, a new position was created at Steps; a Program Specialist position. This staff person is responsible now to complete all paperwork necessary for the files; and to ensure that all paperwork and information in the files are in accordance to the regulations. The Assistant Director is going to meet with the Program Specialist on January 23rd to offer further and more detailed training on the regulations and what is required to be completed in the individuals' files. Also, a more detailed checklist was developed to be used when auditing the files. The Program Specialist will utilize this checklist when she audits the files. She will audit all files this week to ensure that each individual has had a TB test within the required time frame. The Assistant Director will then also audit the files as well. Moving forward, the Program Specialist will audit all of files on a quarterly basis. The Assistant Director will audit all of the files on an annual basis. [Immediately, the CEO or designee shall develop and implement a tracking and notification system to ensure timely completion of all individuals' physical examinations including Tuberculin Skin testing. Documentation of aforementioned audit by the Program Specialist(s) and Assistant Director shall be kept. (DPOC by AES,HSLS on 1/23/19)] 01/25/2019 Implemented
2380.111(c)(8)Individual #3's physical examination completed 7/30/18 did not include physical limitations of the individual. This section was left blank. [Repeated Violation-1/30/18]The physical examination shall include: Physical limitations of the individual.The incomplete physical form was faxed to the doctor by the Director on January 11, 2019. The form was completed in full by the doctor and was returned back to Steps; and the Director placed the form in the individual's file on January 15, 2019. A memo was written and presented to the staff at Steps on January 14th on the importance of having all of the information on the physical form filled in completely; and all staff signed the memo. Starting January 2, 2019, a new position was created at Steps; a Program Specialist position. This person is responsible for completing all paperwork in the files; and ensuring that everything in the files meets the regulations. The Assistant Director will train the Program Specialist on January 24th in a more detailed fashion on how to audit the files to ensure that everything in the file is in accordance to the regulations. A more detailed checklist was developed; which will be utilized by the Program Specialist when she audits the files. The Program Specialist will audit all of the files this week; specifically looking at the physical forms to ensure that no information was left incomplete on any of the forms. The Assistant Director will then audit the files as well, to make sure everything was done correctly. Documentation of the audits will be kept. Moving forward, the Program Specialist will audit all of the files on a quarterly basis. The Assistant Director will audit the files on an annual basis. 01/25/2019 Implemented
2380.111(c)(10)Individual #2's physical examination completed 7/2/18 did not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #3's physical examination completed 7/30/18 did not include medical information pertinent to diagnosis and treatment in case of an emergency. These sections were blank. [Repeated Violation-1/30/18]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The incomplete physical forms were faxed to the doctor by the Director on January 11, 2019. The forms was completed in full by the doctor and were returned back to Steps; and the Director placed the forms in the individual's files on January 15, 2019. A memo was written and presented to the staff at Steps on January 14th on the importance of having all of the information on the physical form filled in completely; and all staff signed the memo. Starting January 2, 2019, a new position was created at Steps; a Program Specialist position. This person is responsible for completing all paperwork in the files; and ensuring that everything in the files meets the regulations. The Assistant Director will train the Program Specialist on January 24th in a more detailed fashion on how to audit the files to ensure that everything in the file is in accordance to the regulations. A more detailed checklist was developed; which will be utilized by the Program Specialist when she audits the files. The Program Specialist will audit all of the files this week; specifically looking at the physical forms to ensure that no information was left incomplete on any of the forms. The Assistant Director will then audit the files as well, to make sure everything was done correctly. Documentation of the audits will be kept. Moving forward, the Program Specialist will audit all of the files on a quarterly basis. The Assistant Director will audit the files on an annual basis. 01/25/2019 Implemented
SIN-00128430 Renewal 01/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #4, date of admission 8/2/17, had physical examinations completed on 7/26/16 and 8/15/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Jessica Henry, Program Specialist, assisted Individual#4 contact her doctor. She spoke with her aunt on 2-5-18 to get the information on which doctor to call. They called the doctor's office and left a message. Individual #4 got no call back from the doctor, so they called again on 2-6-18. After several attempts to call the office and only ever getting the answering machine, Jessica accompanied Individual #4 to the office on 2-12-18 and set up an appointment for February 26, 2018 at 10:30 a.m. This was the first available appointment. Cassie Eiselman, Assistant Director wrote a memo regarding the need for individuals to have a physical examination within 12 months prior to admission and annually after that. JoAnn Hawk, Executive Director, presented the memo to Steps to Success staff (Jessica Henry, Angelica Cerra and Kayla Harrington) and trained them on the memo on 2-2-18. They signed and dated the memo, acknowledging that they understood the training. Jessica Henry will be responsible for ensuring that a physical form is received for each individual prior to their admission to Steps to Success; and that physicals are received annually after that. [Immediately, the program specialist shall develop and implement a tracking and notification system for individuals' physical examination to ensure completion, timely. At least quarterly for 1 year, the Executive director shall review the tracking system to ensure timely completion of individuals' physical examinations. (AS 2/16/18)] 02/26/2018 Implemented
2380.111(c)(3)Individual #1's physical examination completed 10/19/17 did not include Immunizations. Individual #2's physical examination completed 2/27/17 did not include Immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Cassie Eiselman, Assistant Director, contacted the residential provider where Individual #2 lives on 2-1-18. They do not require immunizations; so had no immunizations for him. Jessica Henry, Assistant Director, contacted his mother about his immunizations. She gave the doctor's contact info. to Jessica. Jessica contacted them on 2-6-18. They said that the info on the immunizations was in storage; and needed to be found. They said as soon as they were found, they would fax them. The list on immunizations was faxed to ICW on 2-12-18; and was filed on 2-13-18. Jessica Henry assisted Individual #1 to call her Doctor's office and her list of immunizations was faxed to the ICW office on 2-14-18; and filed in her file on 2-15-18. Cassie Eiselman (Assistant Director) wrote a memo addressing the need to have immunizations with the physicals. JoAnn Hawk (Executive Director) trained Jessica Henry, Kayla Harrington and Angelica Cerra on this matter on 2-2-18. They signed and dated, signifying that they attended and understood the training. Jessica Henry will be responsible for ensuring that a list of immunizations is received with each individual physical for now on. [Immediately and upon receipt of physical examinations, the program specialist shall audit the individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 2/16/18)] 02/16/2018 Implemented
2380.111(c)(4)Individual #1's physical examination completed 10/19/17 did not include a vision and hearing screening. Individual #4's physical examination completed 8/15/17 did not include a vision and hearing screening. The vision screening was left blank. The hearing screening had both normal and abnormal marked with check marks.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #1 had a new physical done on February 12, 2018. This was a result of Jessica Henry, Program Specialist talking with her and her mother and assisting Individual #1 to schedule the appointment and providing her with the ICW physical form to take to the appointment. The physical was completed in entirety by the doctor, with the vision and hearing section completed. Individual #4 will have her physical on February 26th at 10:30. Jessica Henry assisted her in setting up this appointment time with her doctor. It is their first available appointment. Jessica gave her the proper form to take to the appointment, and she will ensure that it is completed entirely, with the vision and hearing section completed. Cassie Eiselman, Assistant Director,wrote a memo concerning the need to ascertain that all physicals are completed with no sections left blank or completed incorrectly. JoAnn Hawk, trained Jessica Henry, Kayla Harrington, and Angelica Cerra on this memo on 2-2-18. They signed and dated the memo that they attended the training and understood. Jessica Henry will be responsible for checking all physicals for all individuals attending Steps to Success for completeness; and working with the individuals and their families if the information is not complete. [Immediately and upon receipt of physical examinations, the program specialist shall audit the individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 2/16/18)] 02/26/2018 Implemented
2380.111(c)(5)Individual #1's physical examination completed 10/19/17 did not include a Tuberculin skin testing with negative results. Individual #4, date of admission 8/2/17 had Tuberculin skin testing with negative results read on 8/15/17.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.Individual #1 had a new physical completed on February 12, 2018. Jessica Henry, Program Specialist, worked with her and her mother to make the appointment and gave her the proper form to take with her. The doctor had done the TB test on February 6th and it was read on February 8th. This information was completed on the physical form. ICW received the form on 2-12-18 and it was placed in her file on 2-13-18. Individual# 4 will be having a physical, and TB test on 2-26-18 at 10:30 a.m. The TB test will be read on 2-28-18. This is the earliest appointment she could get. Jessica Henry helped her set up the appointment. After several phone calls and several failed attempts to get through to the doctor's office, Jessica took Individual #4 to the office to set up the appointment. Cassie Eiselman(Assistant Director) wrote a memo on the importance of each individual attending Steps to Success having a TB test; and JoAnn Hawk(Excecutive Director)presented it to the Steps staff (Jessica Henry, Kayla Harrington and Angelica Cerra) on 2-2-18. They signed and dated that they understood the training. Jessica Henry will be responsible for ensuring that all applicants to Steps have a completed TB test indicating there is no presence of TB prior to admission.[Immediately and upon receipt of physical examinations, the program specialist shall audit the individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 2/16/18)] 02/26/2018 Implemented
2380.111(c)(6)Individual #1's physical examination completed 10/19/17 did not address communicable disease; therefore, compliance could not be measured.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.Jessica Henry, Program Specialist, assisted Individual #1 and her mother in scheduling a new physical examination for her. She also provided her with the proper form to take with her. Individual #1 had a new physical on February 12, 2018. It was completed by the doctor; and the section was completed indicating that Individual #1 is free from communicable diseases. The physical was faxed to ICW on February 12th; and was placed in Individual #1's file on February 13, 2018. A memo was written by Cassie Eiselman, Assistant Director on 2-2-18, concerning the need to make sure that all physicals are completed in their entirety, with no sections left blank. JoAnn Hawk, Executive Director, trained the Steps to Success staff, Jessica Henry, Kayla Harrington and Angelica Cerra on this memo on 2-2-18; and they all signed and dated that they attended and understood the training. Jessica Henry will be responsible for double checking all physicals for all individuals to make sure they are filled out entirely with nothing left blank. If information is left blank or is not included on the form, she will work with the individuals to contact their doctors to have the information filled out.[Immediately and upon receipt of physical examinations, the program specialist shall audit the individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 2/16/18)] 02/12/2018 Implemented
2380.111(c)(8)Individual #1's physical examination completed 10/19/17 did not include the physical limitations of the individual.The physical examination shall include: Physical limitations of the individual.Jessica Henry, Program Specialist, assisted Individual #1 and her mother schedule a new physical exam for her, and gave her the proper form to take with her. Individual #1 had a new physical completed on February 12, 2018. The form was completed correctly by the doctor, and included the physical limitation of the individual; specifically that there were none. The completed form was received by fax at ICW on 2-12-18 and was placed in her file on 2-13-18. Cassie Eiselman, Assistant Director, wrote a memo addressing the need to make sure that all physicals are completely filled out. JoAnn Hawk, Executive Director, trained the Steps to Success staff(Jessica Henry, Kayla Harrington and Angelica Cerra) on this matter on 2-2-18; and they all signed and dated the memo that they both attended and understood the training. Jessica Henry will be responsible for double checking that all physical forms for all individuals attending Steps to Success are completely filled out, with nothing left blank. If information is left incomplete, she will assist the individual and their family to contact their doctor to have the information completed correctly.[Immediately and upon receipt of physical examinations, the program specialist shall audit the individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 2/16/18)] 02/13/2018 Implemented
2380.111(c)(10)Individual #1's physical examination completed 10/19/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination completed 2/27/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Jessica Henry, Program Specialist, assisted Individual #1 and her mother schedule an appointment with her doctor to have all the missing info. on her physical completed. She had a new physical on 2-12-18 with her doctor. The doctor completed the information on medical information pertinent to diagnosis and treatment in case of an emergency. ICW received the completed physical form via fax on 2-12-18 and it was placed in her file on 2-13-18. Jessica Henry assisted Individual #2 to schedule a physical with his doctor for 2-7-18. His mother cancelled the physical that day, because of bad weather. Another appointment was made for 2-14-18. Individual #2's mother ended up cancelling that appointment on that day for unknown reasons. Jessica called and spoke with his mother about the importance of getting the physical completed. Another appointment was set up for 2-19-18 at 1:45. Cassie Eiselman (Assistant Director) wrote a memo about the importance of ensuring that all of the physical form is complete. JoAnn Hawk (Executive Director) met with Jessica Henry, Angelica Cerra and Kayla Harrington on 2-2-18 and trained them on this matter. Jessica Henry will be responsible for checking all physical forms for all individuals to make sure that they are filled out completely; with nothing left blank. She will work with the individuals and their families to get any missing information, if anything is left blank or is not included with the physical form.[Immediately and upon receipt of physical examinations, the program specialist shall audit the individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 2/16/18)] 02/19/2018 Implemented
2380.111(c)(11)Individual #1's physical examination completed 10/19/17 did not include special instructions for the individual's diet. Individual #2's physical examination completed 2/27/17 did not include special instructions for the individual's diet.The physical examination shall include: Special instructions for an individual's diet.Jessica Henry, Program Specialist, helped Individual #1 and her mother schedule an appointment with her doctor to have the missing information completed on the proper physical form. She had her appointment on 2-12-18. The missing information was completed and the form was faxed to ICW. It was placed in her file on 2-13-18. Jessica Henry assisted Individual #2 to schedule a doctor appointment to get this information for 2-7-18. His mother cancelled that day, due to bad weather. Another appointment was scheduled for 2-14-18. His mother cancelled that appointment also, for unknown reasons. Jessica called and spoke to Individual #2's mother about the importance of him getting a physical and having this information completed. An appointment was scheduled for 2-19-18 at 1:45. Cassie Eiselman wrote a memo, and JoAnn Hawk, presented it to Steps staff, Jessica Henry, Kayla Harrington and Angelica Cerra, about the need to ensure that all physical forms are filled out completely. They signed and dated the memo that they understood the training. It will be Jessica Henry's responsibility to ensure that all physicals of all individuals are filled out completely; with no information left blank. If anything is left blank, she will work with the individuals and their families to contact their doctors for the missing information.[Immediately and upon receipt of physical examinations, the program specialist shall audit the individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 2/16/18)] 02/19/2018 Implemented
2380.181(e)(8)Individual #1's assessment completed 11/28/17 did not include the Individual's ability to evacuate in the event of a fire.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.Individual #1's assessment contained an incomplete sentence regarding her ability to evacuate in the event of a fire. Jessica Henry, Program Specialist, redid her assessment on 2-5-2018; and completed the sentence, indicating that individual #1 understands the dangers of fire and can evacuate the premises independently. This assessment was then placed in individual #1's file on 2-5-2018. Cassie Eiselman (Assistant Dir) wrote a memo, instructing the Steps to Success staff to double-check and proofread all work, to ensure that nothing is left blank or incomplete. JoAnn Hawk (Executive Director) trained the Steps to Success staff(Kayla Harrington, Jessica Henry and Angelica Cerra) on the memo on February 2, 2018. They signed and dated the memo, signifying that they understood the training. Jessica Henry will be responsible to review and sign off on all assessments, reports and other paperwork completed by Kayla Harrington and Angelica Cerra from now on; and she will do a file review of all individual files quarterly to ensure that all files are in line with the 2380 regulations. [Upon competition by the program specialist, for at least 1 year, the Executive Director shall audit all individuals' assessments to ensure the program specialist completed the assessment with all required information. Documentation of the audits shall be kept. (AS 2/16/18)] 02/12/2018 Implemented
2380.181(e)(12)Individual #1's assessment completed 11/28/17, Individual #2's assessment completed 9/30/17, Individual #3's assessment completed 11/1/17 and Individual #4's assessment completed 8/2/17 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Cassie Eiselman, Assistant Director, developed a new assessment form for Steps to Success on 2-2-2018; which included a section for recommendations for specific areas of training, vocational programming and competitive community-integrated employment. She also wrote a memo, informing the Steps to Success staff of this new form. JoAnn Hawk, Executive Director, trained Kayla Harrington, Jessica Henry and Angelica Cerra on the new form on 2-2-18; and they signed and dated that they understood the training. Jessica Henry redid individual #1's assessment, including this information on 2-5-18 and placed the assessment in the file on 2-6-18, after individual #1 had signed it. She then redid individual #2's assessment on 2-5-18 also, and placed it in the file on 2-6-18, after individual #2 had signed it. Individual #3's assessment was redone on 2-6-18 and placed in the file 2-6-18,after they signed it. And individual #4'a assessment was redone on 2-6-18 as well; and placed in the file on 2-7-18; after they had signed it. Moving forward, Jessica Henry will be responsible to make sure that the new assessment form is used at all times. She will review any and all assessments written by Angelica or Kayla. She will also review all of the files quarterly for correctness and completeness.[Upon competition by the program specialist, for at least 1 year, the Executive Director shall audit all individuals' assessments to ensure the program specialist completed the assessment with all required information. Documentation of the audits shall be kept. (AS 2/16/18)] 02/12/2018 Implemented
2380.181(e)(13)(iv)Individual #1's assessment completed 11/28/17, Individual #2's assessment completed 9/30/17, Individual #3's assessment completed 11/1/17 and Individual #4's assessment completed 8/2/17 did not include individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The assessment form did not have a space for this information.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.Cassie Eiselman, Assistant Director, developed a new assessment form for Steps to Success on 2-2-2018, which included a section for progress over the last 365 calendar days and current level in the following areas: Socialization. She also wrote a memo, informing the Steps to Success staff of this new form. JoAnn Hawk, Executive Director, trained Kayla Harrington, Jessica Henry and Angelica Cerra on the new form on 2-2-2018; and they signed and dated the memo that they understood it. Jessica Henry redid the assessments with the new form; individual #1 on 2-5-18; filed 2-6-18; Individual #2 on 2-5-18; filed 2-6-18; individual #3 on 2-6-18; filed 2-6-18 and individual #4 on 2-6-18; filed 2-7-18. Jessica Henry will be responsible to make sure that the new assessment form is used at all times. She will review all assessments written by Kayla Harrington and Angelica Cerra. She will also review all of the individuals' files quarterly for completeness and correctness.[Upon competition by the program specialist, for at least 1 year, the Executive Director shall audit all individuals' assessments to ensure the program specialist completed the assessment with all required information. Documentation of the audits shall be kept. (AS 2/16/18)] 02/12/2018 Implemented
2380.181(e)(14)Individual #1's assessment completed 11/28/17, Individual #2's assessment completed 9/30/17, Individual #3's assessment completed 11/1/17 and Individual #4's assessment completed 8/2/17 did not include the individual's knowledge of water safety and ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Cassie Eiselman, Assistant Director, developed a new assessment form for Steps to Success on 2-2-2018; which included a section for The individual's knowledge of water safety and ability to swim. She also wrote a memo, explaining the new assessment form. JoAnn Hawk, Executive Director, provided training to the Steps to Success staff, Jessica Henry, Kayla Harrington and Angelica Cerra, on the new assessment form on 2-2-2018; and they all signed and dated the memo, that they had received and understood the training on the new form. Jessica Henry redid the existing assessments using the new form; individual #1 on 2-5-18; filed 2-6-18; individual #2 on 2-5-18; filed on 2-6-18; individual #3 on 2-6-18; filed 2-6-18; and individual #4 on 2-6-18; filed on 2-7-18. Jessica Henry will be responsible to review all assessment forms completed by Kayla Harrington and Angelica Cerra. She will also review all of the individuals attending Steps to Success files on a quarterly basis to make sure they are completely in compliance with the regulations.[Upon competition by the program specialist, for at least 1 year, the Executive Director shall audit all individuals' assessments to ensure the program specialist completed the assessment with all required information. Documentation of the audits shall be kept. (AS 2/16/18)] 02/12/2018 Implemented
2380.186(e)The program specialist did not notify all the plan team members including family members for Individual #1, Individual #3 and Individual #4 of the option to decline the ISP review documentation .The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Jessica Henry, Transition Service Coordinator, is the Program Specialist for Steps to Success. She contacted the family members of individual's #1,#3 and #4 on February 1, 2018. Individual #1's mother came to the office and signed a letter requesting the documentation be given to her. This letter was then placed in her file on 2-2-18. Individual #3's father came to the office and signed a letter, he also requested documentation be sent to him. This was placed in Individual #3's file on 2-2-18. Individual #4's aunt came to the office on 2-2-18; and signed a letter. She requested the documentation be sent to her as well. The letter was placed in Individual #4's file on 2-2-18. Cassie Eiselman(Assistant Director) wrote a memo, instructing the staff of Steps to Success to take blank letters to all ISP meetings and to have them completed at the ISP meeting by all plan team members (with the exception of the Supports Coordinators), indicating whether plan team members want or decline to have the ISP review documentation sent to them. These letters will then be placed in the individuals' files. JoAnn Hawk (Executive Director) met with the Steps to Success staff (Kayla Harrington, Jessica Henry and Angelica Cerra) on 2-2-18 and trained them on the memo. It will be the responsibility of Jessica Henry as the Program Specialist to review all of the individual's files on a quarterly basis, to ensure that all ISP plan members signed the letters at the ISP meeting and that the letters were then placed in each of the individuals' files. [Documentation of the quarterly file reviews shall be kept. (AS 2/16/18)] 02/12/2018 Implemented
SIN-00108731 Initial review 02/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The cleaning products in the janitors room were not locked.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.A locked cabinet was purchased on Thursday, February 16, 2017 at Lowe's. This cabinet will be used to store poisonous materials located in a space occupied by the Lessor's janitor. This area is not included in our leased space; however, will be used as an alternative emergency exit passageway in the event of an emergency. The cabinet was assembled on Friday, February 17, 2017 and all poisonous materials were placed in it. (picture emailed to Licensing Representative) [Prior to hire all staff persons shall be educated that poisonous materials shall be kept locked or made inaccessible to individuals when not in use and the agencies procedures to ensure poisonous materials are locked and inaccessible and to monitor throughout the courses of their daily duties. Documentation of trainings shall be kept. (AS 2/27/17)] 02/27/2017 Implemented
2380.82The door between the program area and janitors room had a lock on the side of the janitors room which when engaged prevents egress from the program area through the janitors room to the passageway leading to the outside of the building.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.A hall/closet door knob (with no locking mechanism) was purchased on Thursday, February 16, 2017 at Lowe's. The knob was installed on the door between the program area and janitors room which prevents the passageway through the janitors room from any obstructions in the event of an emergency. The knob was installed on Friday, February 17, 2017. (picture emailed to Licensing Representative)[Prior to hire all staff persons shall be educated that stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed and to monitor throughout the courses of their daily duties. Documentation of trainings shall be kept. (AS 2/27/17)] 02/27/2017 Implemented
2380.90(b)The way to reach the exit through janitors room to the passageway to the outside of the building is not immediately visable and access to the exit was not market with visable signs indicating the direction of travel.If the exit or way to reach the exit is not immediately visable to the individuals, access to exits shall be marked with visible signs indicating the direction of travel.A replacement "EXIT" sign was purchased on Thursday, February 16, 2017 at Lowe's. The "EXIT" sign was hung above the door of the alternative exit through the janitors room to the passageway to the outside of the building on Friday, February 17, 2017. The "EXIT" sign has an arrow which clearly indicates the direction of travel in the event of an emergency. (picture was emailed to Licensing representative)[At least quarterly, a designated staff person shall complete an onsite walk through of the facility to ensure exits signs including direction of travel signs are in place as required. (AS 2/27/17)] 02/27/2017 Implemented
SIN-00241669 Renewal 03/26/2024 Compliant - Finalized
SIN-00187586 Renewal 05/17/2021 Compliant - Finalized
SIN-00168255 Renewal 12/19/2019 Compliant - Finalized