Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262538 Renewal 03/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)At 3:20 PM, a one-quart bottle of Formula 409 Cleaner and Degreaser; a 22-fluid ounce bottle of Resolve Spot and Stain Carpet Cleaner; a 17.5-ounce can of Raid Ant and Roach Killer; a 40-fluid ounce bottle of Mean Green Super Strength Cleaner and Degreaser; a 48-fluid ounce bottle of Bissell Pro Max Carpet Cleaner; a 12.5-ounce can of Pledge Furniture Care Cleaner; and a 19-ounce can of Lysol Disinfectant Spray were unlocked and accessible in the storage closet in the hallway outside of the program area.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The POC is that the chemicals/cleaners are now in a locked cabinet inside of the closet. The Program Specialist has told Direct Support Staff that all chemicals/cleaners are to remain inside the locked cabinet when not in use. The key for the cabinet is in 2 locations, one in the safe and one with the Program Specialist. Pictures have been emailed to show it has been corrected. 03/13/2025 Implemented
2380.53(b)At 3:27PM, a spray bottle with "Sanitizer" handwritten on it that was half full of a clear liquid and an unlabeled 32-ounce plastic spray bottle half full of an unknown yellowish solution were stored with other cleaning products in the storage closet in the hallway outside of the program area.Poisonous materials shall be stored in their original, labeled containers.When Program Specialist was made aware, that day the two bottles were disposed of. Program Specialist then told Direct Support Staff that all chemicals/cleaners are to remain in their original packaging. There are no longer any bottles that can be used for anything else inside of the offices. 03/13/2025 Implemented
2380.88(a)At 3:28 PM, the fire extinguisher in the programming area had a 1-A rating.There shall be at least one fire extinguisher with a minimum 2-A rating for each floor including the basement.Once Program Specialist was made aware, Program Specialist went onto amazon and purchased a fire extinguisher with the correct rating. The receipt for the fire extinguisher is provided by being taped on the side. Program Specialist also told Direct Support Staff the correct rating the fire extinguisher should be, so they are also aware. Photo has been sent in. 03/13/2025 Implemented
2380.111(c)(6)Individual #1 physical examination, completed 8/7/24 did not address communicable disease. The notation on the physical examination read "unable to evaluate" and the yes or no question, "Exam reveals individual is free from contagious disease" was left blank.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.Program Specialist immediately reached out to the Program Specialist of the client's home. Our company's policy was then put into effect that the client is since suspended until client is able to show if they are Y/N for the communicable diseases. Once we have the results of that back, client will be accepted into the program. 03/13/2025 Implemented
2380.111(c)(7)Individual #3's physical examination, completed 11/7/24 did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section was left blank.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.Program Specialist had missed not seeing the information on the form. Program Specialist contacted the individual's house, Program Specialist. The Program Specialist for the individual, sent over the physical and attached documents they were given at the appointment. 03/13/2025 Implemented
2380.111(c)(10)Individual #3's physical examination completed 11/7/24 did not include medical information pertinent to diagnosis and treatment in the 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.Program Specialist had missed not seeing that information on the form. Program Specialist contacted the individual's house, Program Specialist. The Program Specialist for the individual, sent over the physical and attached documents they were given at the appointment. 03/13/2025 Implemented
2380.176(a)At 3:45 PM, the four individuals' medical and program records were unlocked and unattended on a shelf in the interpreting coordinator's office.Individual records shall be kept locked when they are unattended.Program Specialist had reached out and got a locking filing cabinet. The locking filing cabinet has been placed in a closet with all individual's files and staff files. Program Specialist has a key, and the other key is in a safe, Direct Support Staff have been made aware. Photo submitted. 03/13/2025 Implemented
2380.38(b)(2)The orientation for Direct Service Worker #1, date of hire 2/20/24, did not encompass the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Program Specialist has made a check list for orientations. Checklist will be completed by any new Direct Support Staff and then used again by the Program Specialist to ensure that they are completed. 03/13/2025 Implemented
2380.38(b)(4)The orientation for Direct Service Worker #1, date of hire 2/20/24, did not encompass recognizing and reporting incidents.The orientation must encompass the following areas: Recognizing and reporting incident.Program Specialist has made a check list for orientations. Checklist will be completed by any new Direct Support Staff and then used again by the Program Specialist to ensure that they are completed. 03/13/2025 Implemented
2380.39(c)(2)The annual training for calendar year 2024 for Direct Service Worker #2 did not encompass prevention, detection and reporting of abuse, suspected abuse, and alleged abuse.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Program Specialist has since made a checklist for the Direct Support Staff. This checklist will be used by Direct Support Staff to keep track of their trainings, and then used again by the Program Specialist to check off that the staff did complete their trainings. 03/13/2025 Implemented
2380.39(c)(4)The annual training for calendar year 2024 for Direct Service Worker #2 did not encomplass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Program Specialist has since made a checklist for the Direct Support Staff. This checklist will be used by Direct Support Staff to keep track of their trainings, and then used again by the Program Specialist to check off that the staff did complete their trainings. 03/13/2025 Implemented
2380.182(c)Individual #2's assessment, completed 3/22/24 indicates that he is independent in fire evacuation. In the fire safety section of Individual #2's individual plan last updated 11/27/24 reads, "[Individual #2] would need assistance in evacuating in the event of a fire. [Individual #2] may require physical assistance to exit quickly and safely due to his cerebral palsy and currently he is using a walker at all times due to a hip surgery in July 2023". Individual #3's assessment, completed 3/21/24 indicated that he can independently sense and quickly move away from dangerous heat sources. In the physical development section of Individual #3's individual plan, last updated 1/17/25 reads, "[Individual #3] needs minimal supervision near heat sources. Staff are in eyesight when [Individual #3] is around heat sources."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Program Specialist had reached out to the individual's Support Coordinator regarding adding a section in the ISP. In the ISP there will now be a section for HDS Day Program stating that the individual only needs handed his walker, unless asks otherwise. Program Specialist also adjusted the heat source section of the assessment to ensure it matches the individual's plan and is correct for the individual. 03/13/2025 Implemented
SIN-00241184 Renewal 03/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The fire drill conducted on 10/26/23 had an evacuation time of 2:47 minutes. The fire drill conducted on 11/22/23 had an evacuation time of time of 2:51 minutes. The fire drill conducted on 12/22/23 had an evacuation time of time of 4:13 minutes. The fire drill conducted on 1/30/24 had an evacuation time of time of 2:52 minutes. The fire drill conducted on 2/20/24 had an evacuation time of time of 5:40 minutes. The facility does not have an extended evacuation time specified by a fire safety expert.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.Program Specialist was taught prior to inspection to start the timer when the fire alarm goes off and turn it off when everyone meets at the meeting point, making the time very long. In inspection, Program Specialist was taught to stop the timer when last client exits building. In the next fire drill, Program Specialist timed it correctly and got the time to 1 min and 45 seconds. Fire drills will only be documented by the Program Specialist who will be involved in every fire drill. 03/27/2024 Implemented
2380.111(a)Individual #1, date of admission 2/24/23, had an initial physical examination completed 3/7/23.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual's physical was given to us after they had already started the program. Program Specialist had thought that the physical could be completed within 30 days of when the client started the program. Program Specialist is now aware that it must be completed prior to starting the program. The individual's staff/family will be made aware of this when there is interest shown about attending the program. There will not be a start date given until we have the physical in hand. 03/27/2024 Implemented
2380.111(c)(5)Individual #1, date of admission 2/24/23, had an initial Tuberculin skin testing with negative results completed 3/9/23.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's tb shot results were given to us after they had already started the program. Program Specialist had thought that the tb shot results could be completed within 30 days of when the client started the program. Program Specialist is now aware that it must be completed prior to starting the program. The individual's staff/family will be made aware of this when there is interest shown about attending the program. There will not be a start date given until we have the tb shot results in hand. 03/27/2024 Implemented
2380.181(f)There was not documentation as to when the Individual #3's assessment, completed 1/5/24 was provided to the individual plan team members for Individual #1's annual individual plan meeting on 2/21/2024; therefore, compliance could not be measured. (Repeated violation 4/14/23.)The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Individual's file did not have the email showing that Program Specialist had sent out the Functional Analysis 30 days before the ISP meeting. Program Specialist will print the email showing it has been sent as soon as it is sent to the individual's team. 03/27/2024 Implemented
SIN-00222825 Renewal 04/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1, date of admission 11/1/22, did not have a training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, and smoking safety procedures.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.Fire safety training will be done on the day of admission in conjunction with the client's ability medically and functionally. Fire safety training has been added to the new admission initial check list to be forwarded to licensing. 05/15/2023 Implemented
2380.181(a)Individual #1, date of admission 11/1/22 did not have an initial assessement.Each individual 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.A functional analysis will be done for each individual within 60 calendar days after admission to the HDS CPS program and annually thereafter by the program specialist. This will be cited on the initial and annual check list. 05/15/2023 Implemented
2380.181(e)(6)Individual #2's assessment, completed 2/14/23, did not include the individual's ability to safely use or avoid poisons. Program Specialist #3 marked this field as "not applicable."The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.All functional analysis will include a rating instead of not applying (N/A) checked off on the report. This will be for all individuals. The program specialist is responsible for administering the functional analysis. 05/15/2023 Implemented
2380.181(e)(7)Individual #3's assessment, completed 4/15/21, did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly. This field was not included on the assessment. Individual #2's assessment, completed 2/14/23, did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly. Program Specialist #3 marked this field as "not applicable."The assessment must include the following information: The individual¿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.All functional analysis will include a rating instead of not apply (N/A) checked off on the report for danger of heat sources and ability to sense and move away quickly. This will be for all individuals. The program specialist is responsible for administering the functional analysis. 05/15/2023 Implemented
2380.181(e)(8)Individual #2's assessment, completed 2/14/23, did not include the individual's ability to evacuate in the event of a fire. Program Specialist #3 marked this field as "not applicable."The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.All functional analysis will include a rating instead of not apply (N/A) checked off on the report for ability to evacuate in the event of a fire. This will be for all individuals. The program specialist is responsible for administering the functional analysis. 05/15/2023 Implemented
2380.17(g)On 2/16/23, during Individual #2's individual plan meeting, Direct Service Worker #2 reported that she witnessed a staff member from another agency physically push Individual #2 on 12/20/22. The facility did not initial an investigation until 2/21/23.The facility shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.All staff will or have been retrained on mandated reporting reviewing and signing off on 2380.17(g) and taking training through My ODP. The program specialist is responsible for monitoring this requirement. 05/15/2023 Implemented
2380.21(u)Individual #1, date of admission 11/1/22, was not informed and explained individual rights upon admission.The 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.Informing and explaining individual rights will be conducted on the day of admission. This has been added to the new client initial checklist. 05/15/2023 Implemented
2380.39(c)(2)Direct Service Worker #1's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include prevention, detection and reporting of abuse, suspected abuse, and alleged abuse. Direct Service Worker #2's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include prevention, detection and reporting of abuse, suspected abuse, and alleged abuse. Program Specialist #3's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Although Program Specialist 3 believes staff 1, 2 and 3 did complete training including prevention, detection and reporting of abuse, suspected abuse, and alleged abuse. All staff followed the POC for training missed in 2020 in 2021 and 2022. However, all staff will receive training in these areas as prescribed in 6100 and 2380 during calendar year 2023. A list of approved trainings will be emailed to licensing and completed this calendar year and tracked by the program specialist. 05/15/2023 Implemented
2380.39(c)(5)Direct Service Worker #1's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include safe and appropriate use of behavior supports. Direct Service Worker #2's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include the safe and appropriate use of behavior supports. Program Specialist #3's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include the safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Although Program Specialist 3 believes staff 1, 2 and 3 did complete training including include safe and appropriate use of behavior supports because all staff followed the POC for training missed in 2020 in 2021 and 2022. However, all staff will receive training in these areas as prescribed in 6100 and 2380 during calendar year 2023. A list of approved trainings will be emailed to licensing and completed this calendar year and tracked by the program specialist. 05/15/2023 Implemented
2380.39(c)(6)Direct Service Worker #1's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include the implementation of the individual plan. Direct Service Worker #2's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include implementation of the individual plan. Program Specialist #3's annual training hours for training year, January 1, 2022 to December 31, 2022, does not include 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.Although Program Specialist 3 believes staff 1, 2 and 3 did complete training including implementation of the individual plan because all staff followed the POC for training missed in 2020 in 2021 and 2022. However, all staff will receive training in these areas as prescribed in 6100 and 2380 during calendar year 2023. A list of approved trainings will be emailed to licensing and completed this calendar year and tracked by the program specialist. 05/15/2023 Implemented
2380.181(f)The program specialist provided Individual #2's assessment, completed 2/14/23, to individual #2's plan team members on 2/16/23 for the individual plan meeting on 2/16/23.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.This was due to program specialist oversight and the support coordinator¿s not giving a month notice of the meeting. Program Specialist 3 completed and emailed the 2/14/2023 and the ISP meeting was on 2/16/2023. The program specialist will put an alert in MS WORD 60 days before the next annual ISP should occur to get the functional analysis out to the team 30 days before the ISP meeting. 05/15/2023 Implemented
2380.17(a)(5)On 2/16/23, during Individual #2's individual plan meeting, Direct Service Worker #2 reported that she witnessed a staff member from another agency physically push Individual #2 on 12/20/22. The facility did not report the allegation of abuse into the Department's information management system until 2/21/23.The facility should 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: Neglect.All staff, if they witness possible abuse will report it to the point person immediately and the point person will inform the team and agencies that may need contacted. 05/15/2023 Implemented
SIN-00203926 Renewal 04/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Direct Service Worker#2 had a physical examination completed 2/26/19 then 12/13/21. Direct Service Worker #3 had a physical examination completed 12/9/19 then 4/11/22.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.This was due to Program Specialist oversight. Staff #2 and #3 both said they weren't prompted by the program specialist in a timely manner. Staff number 3 said they had a change of physician but does not have any communication showing this. The Program Specialist, with the help of our IT dept. will set up a calendar in Outlook with the dates of the current physical for all staff. There will also be a 120 day reminder , for each date, to alert the Program Specialist and staff of that up coming physical. 05/27/2022 Implemented
2380.113(c)(2)Direct Service Worker#2 had a Tuberculin skin testing with negative results completed 11/16/18 then 4/29/21. Direct Service Worker #3 had a Tuberculin skin testing with negative results 12/12/19 then 1/26/22.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.This was due to Program Specialist oversight . Staff #2 and #3 both said they weren't prompted by the program specialist in a timely manner. Staff number 3 said they had a change of physician but does not have any communication showing that. The Program Specialist, with the help of our IT dept. will set up a calendar in Outlook with the dates of the current TB for all staff. There will also be a 120 day reminder ,for each date, to alert the Program Specialist and staff of up coming TB test. 05/27/2022 Implemented
2380.173(5)Individual #1's record did not include an individual plan meeting signature page or list of attendees for the Annual individual plan meeting conducted on 7/16/21.Individual plan documents as required by this chapter.This was due to Program Specialist oversight. Program specialist #1 will ask SC for copy of the 7/16/2021 signature page or list of attendees for that meeting with individual #1 and every annual plan meeting in the future for individual #1 and all customers henceforth. 05/27/2022 Implemented
2380.181(f)Program Specialist #1 provided Individual #1's assessment, completed 4/15/21, to the individual plan team members on 6/18/21 for the annual individual plan meeting on 7/16/21.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.This was due to Program Specialist oversight. Program Specialist #1 completed the comprehensive functional analysis on 4/15/2021, emailed it to the team on 6/18/2021 before the ISP meeting on 7/16/2021. Program Specialist should have mailed it to the team upon completion but waited until the SC invited the Program Specialist to the ISP meeting on 7/16/2021 making the assessment late. Program Specialist #1 will with the help of IT develop a schedule on their Outlook calendar for individual #1 and all other customers. 05/27/2022 Implemented
SIN-00186806 Renewal 04/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(d)The trash receptacle in the men's bathroom was uncovered.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.This happened due to Program Specialist oversight. I placed a lidded trash can in the restroom on 4/28/2021. A checklist was posted on the back of the restroom door on 5/3/2021. It will be initialed daily by staff to ensure that the lidded trash can has not been removed or compromised. by others. A picture of the lidded trash can and checklist will be emailed to licensing. 05/20/2021 Implemented
2380.39(c)(2)Chief Executive Officer #1 did not complete annual training topic, prevention, detection, and reporting abuse, suspected abuse, and alleged abuse in the training year of 1/1/20-12/31/20. Program Specialist #2 did not complete annual training topic, prevention, detection, and reporting abuse, suspected abuse, and alleged abuse in the training year of 1/1/20-12/31/20. Direct Service Worker #3 did not complete annual training topic, prevention, detection, and reporting abuse, suspected abuse, and alleged abuse in the training year of 1/1/20-12/31/20. Direct Service Worker #4 did not complete annual training topic, prevention, detection, and reporting abuse, suspected abuse, and alleged abuse in the training year of 1/1/20-12/31/20.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.This was due to program specialist oversight. A new training policy and procedure has been developed and staff1, 2, 3, and 4 have been trained in the use of this policy and procedure, All have signed their name to the new policy and procedure acknowledging their understanding there of. Staff 1, 2,3 and 4 have completed abuse training as of 5/20/2021.Proof of training and new training policy and procedure will be emailed to licensing staff. 05/20/2021 Implemented
2380.39(c)(4)Chief Executive Officer #1 did not complete annual training topic of recognizing and reporting incidents in the training year of 1/1/20-12/31/20. Program Specialist #2 did not complete annual training topic of recognizing and reporting incidents in the training year of 1/1/20-12/31/20. Direct Service Worker #3 did not complete annual training topic of recognizing and reporting incidents in the training year of 1/1/20-12/31/20. Direct Service Worker #4 did not complete annual training topic of recognizing and reporting incidents in the training year of 1/1/20-12/31/20.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.This was due to program specialist oversight. A new training policy and procedure has been developed and staff1, 2, 3, and 4 have been trained in the use of this policy and procedure, All have signed their name to the new policy and procedure acknowledging their understanding there of. Staff1, 2,3 and 4 have completed incident management training as of 5/20/2021.Proof of training and new training policy and procedure will be emailed to licensing staff. 05/20/2021 Implemented
2380.39(c)(6)Program Specialist #2 did not complete the annual training topic of implementation of the individual plan in the training year of 1/1/20-12/31/20. Direct Service Worker #3 did not complete the annual training topic of implementation of the individual plan in the training year of 1/1/20-12/31/20. Direct Service Worker #4 did not complete the annual training topic of implementation of the individual plan in the training year of 1/1/20-12/31/20.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.This was due to program specialist oversight. A new training policy and procedure has been developed and staff 2, 3, and 4 have been trained in the use of this policy and procedure, All have signed their name to the new policy and procedure acknowledging their understanding there of. Staff 2,3 and 4 have completed ISP training as of 5/20/2021.Proof of training and new training policy and procedure will be emailed to licensing staff. 05/20/2021 Implemented
SIN-00163267 Renewal 10/28/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1, date of admission 3/1/19, had an initial fire safety training on 10/9/19. Individual #2, date of admission 3/1/19, had an initial fire safety training on 10/10/19. Individual #3, date of admission 6/11/19, had an initial fire safety training on 10/8/19.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in 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.This was due to Program Specialist not being trained After reviewing 2380.91(a) and receiving training new clients will receive fire safety training immediately on the first day of ATF and annually there after. [Immediately, upon hire, at least quarterly for 1 year and then continuing at least annually, the CEO or designee shall educate the program specialist(s) of their responsibilities of the program specialist position. Documentation of the trainings shall be kept. Immediately, upon admission and at least quarterly for 1 year, the Program Specialist shall audit all individuals records to ensure timely competition of fire safety training with all required information. Documentation of audits shall be kept. (DPOC by AES, HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(a)Individual #1, date of admission 3/1/19, had an initial assessment completed 6/6/19. Individual #2, date of admission 3/1/19, had an initial assessment completed 9/5/19. Individual #3, date of admission 6/11/19, had an initial assessment completed 9/13/19.Each individual 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.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(a) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting.[Immediately, upon hire, at least quarterly for 1 year and then continuing at least annually, the CEO or designee shall educate the program specialist(s) of their responsibilities of the program specialist position. Documentation of the trainings shall be kept. Immediately, within 60 days of individual admission and continuing at least quarterly, the Program specialist shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(d)Individual #3's assessment completed 9/13/19 was not signed by Program Specialist #1.The program specialist shall sign and date the assessment.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(d) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. After review by the program specialist he will sign date and send it to the team.[Immediately, upon hire, at least quarterly for 1 year and then continuing at least annually, the CEO or designee shall educate the program specialist(s) of their responsibilities of the program specialist position. Documentation of the trainings shall be kept. Immediately, within 60 days of individual admission and continuing at least quarterly, the Program specialist shall audit all individuals' current assessment to ensure competition and signed and dated by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(1)Individual #2's assessment completed 9/5/19 did not include functional strengths, needs, preferences. This section was blank.The assessment must include the following information: Functional strengths, needs and preferences of the individual.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(1) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(2)Individual #2's assessment completed 9/5/19 did not include likes, dislikes, interests. This section was blank. Individual #3's assessment completed 6/11/19 did not include likes, dislikes, interests. This section was blank.The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(2) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. Likes and dislikes are included on individual #2 's assessment now and will be included in all future assessments. See attachment 5 medical history request emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(3)(iii)Individual #2's assessment completed 9/5/19 did not include personal adjustment. This section was blank.The assessment must include the following information: The individual's current level of performance and progress in the following areas:  Personal adjustment.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(3)(iii) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(3)(iv)Individual #2's assessment completed 9/5/19 did not include personal needs with or without assistance from others. This section was blank.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(3)(iv) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(4)Individual #2's assessment completed 9/5/19 did not include the individual's need for supervision. This section was blank.The assessment must include the following information: The individual's need for supervision.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(4) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S.[Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(6)Individual #2's assessment completed 9/5/19 did not include the individual's ability to safely use or avoid poisonous materials. This section was blank.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(6) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S.[Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the Program specialist shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included in all individuals' current assessments and assessed accurately. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(7)Individual #2's assessment completed 9/5/19 did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F. This section was blankThe assessment must include the following information: The individual'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.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(7) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(8)Individual #2's assessment completed 9/5/19 did not include individual's ability to evacuate in the event of a fire. This section was blankThe assessment must include the following information: The individual's ability to evacuate in the event of a fire.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181e)(8) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(9)Individual #2's assessment completed 9/5/19 did not include documentation of the individual's disability.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(9) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. Attachment 4 was emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(10)Individual #2's assessment completed 9/5/19 did not include the individual's lifetime medical history.The assessment must include the following information: A lifetime medical history.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(10) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 5 medical history request emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(11)Individual #2's assessment completed 9/5/19 did not include a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(11) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand what must be included when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 3 psychological emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(e)(12)Individual #2's assessment completed 9/5/19 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.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181(e)(12) and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting. See attachment 4 emailed to Amy S. [Individual #2 assessment was updated 9/6/19 by the program specialist. Immediately and continuing at least quarterly, the CEO or Designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.33(b)(1)Individual #3's assessment was completed by Direct Service Worker #1 on 9/13/19.The program specialist shall be responsible for the following: Coordinating the completion of assessments.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.33(b)(1) receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office, I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting and that it is my responsibility as program specialist to do the assessment and not delegate to my staff. I will redo the functional assessment and email it to the team now and review the assessment again one month before the ISP meeting sending it to the team again. [Immediately and continuing at least quarterly, the CEO or designee shall audit all individuals' current assessment to ensure competition by the Program Specialist and that all required information is included and accurate in all individuals' current assessments. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.181(f)Program Specialist #1 did not provide Individual #2's assessment, completed 9/5/19 to the plan team members. Program Specialist #1 did not provide Individual #3's assessment, completed 9/13/19 to the plan team members.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.This was due to Program Specialist not being trained in writing functional assessments. After reviewing 2380.181f and receiving training on how to write a functional assessment by the Program Specialist in our Pittsburgh office I now understand when functional assessments are due. 60 days after start date and 30 days before ISP meeting.[Immediately, the Program Specialist shall provide Individual #2 and #3s' assessments to the plan team members and maintain documentation of the correspondence. Immediately, upon hire, at least quarterly for 1 year and then continuing at least annually, the CEO or designee shall educate the program specialist(s) of their responsibilities of the program specialist position. Documentation of the trainings shall be kept. Immediately and continuing at least quarterly, the CEO or designee shall audit the correspondence documentation between the Program specialist and the team members to ensure the Program specialist provides all individuals' current assessments to the plan team members at least 30 days prior to the individuals plan team meeting. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
2380.186Individual #2 is provided food that is cut in small pieces from the residential provider for the lunch time meal. Individual #2 is served the food that is cut in small pieces while at the day program. Individual #2's ISP, updated on 10/16/19 indicates that Individual #2 is on a pureed, 1800 calorie a day diet. Individual #2's physical examination, completed 1/18/19 indicates that Individual #2 is prescribed a pureed diet.The facility shall implement the individual plan, including revisions.This occurred due to ATF following guidelines of clients residential team. The ATF has called for a meeting with the individual's team. The meeting is on 11/8/2019 at 11 a.m. The ATF has invested in a blender that purees and has started this process at lunch time. See attachment 1 and 2 regarding the meeting emailed to Amy S. [Immediately and continuing at least quarterly, the program specialist shall audit all individuals' current individual plans to ensure that all plans are implemented as written. Immediately and upon competition, the program specialist shall audit all individuals' physical examinations to ensure health services are provided and arranged. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 11/19/19)] 11/06/2019 Implemented
SIN-00144973 Initial review 11/08/2018 Compliant - Finalized