Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241563 Renewal 03/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(c)(3)Program Specialist #2 does not have an associate's degree or 60 credit hours from an accredited college or university and only has 2 years 7 months of work experience working directly with persons with disabilities.A program specialist shall have one of the following groups of qualifications: An associate¿s degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with persons with disabilities.Program specialist 2 was replaced on 3/25/24 by an interim Program specialist,. Interim Program Specialist has a Bachelor of liberal arts degree and 20 years of experience working directly with persons with intellectual disabilities. 03/25/2024 Implemented
2380.84The facility did not have an annual onsite fire safety inspection by a fire safety expert in 2022 or 2023. This exceeds the annual requirement.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The office Director has scheduled an immediate fire safety inspection of the facility by the Millcreek Township Fire chief and code enforcement officer. The earliest it could be scheduled is for is 4/11/2024 at 9:30am. 04/11/2024 Implemented
2380.89(a)The facility did not conduct an unannounced fire drill in April 2023 [Repeat violation, 04/05/23].An unannounced fire drill shall be held at least once a month.Program specialist conducted an unannounced fire drill on 5/26/23 and every month subsequently. 05/26/2023 Implemented
2380.113(a)Program Specialist #2, date of 08/16/21, had a physical examination completed on 04/27/22. Program Specialist #2 did not have a physical examination within 12 months prior to employment. Direct Support Professional #3, date of hire 06/13/22, had a physical examination completed on 06/20/22. Direct Support Professional #3 did not have a physical examination within 12 months prior to employment.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.Program coordinator (formerly Program specialist 2) and direct support professional 3 have both gotten physical examinations on 4/27/22 and 6/20/22. 04/01/2024 Implemented
2380.113(c)(2)Program Specialist #2, date of hire 08/16/21, had a Tuberculin skin test completed on 04/29/22. Program Specialist #2 did not have a Tuberculin skin test completed prior to employment. Direct Support Professional #3, date of hire 06/13/22, had a Tuberculin skin test completed on 06/19/22. Direct Support Professional #3 did not have a Tuberculin skin test completed prior to employment.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.Program coordinator (former program specialist 2) and direct support professional 3 have both gotten Tuberculin skin tests on 4/29/22 and 6/19/22. 04/01/2024 Implemented
2380.21(u)Individual #1 was informed and explained individual rights on 10/04/22 and then again on 11/06/23. This exceeds the annual requirement [Repeat violation, 04/05/23].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.Program specialist 1 was let go due to dereliction of duties. When PS 1 was let go the Program coordinator reviewed individual rights to individual 1 as soon as the error was caught, on 11/06/23. 11/06/2023 Implemented
2380.36(b)Program Specialist #2 completed annual fire safety training on 04/12/22 and then again on 05/02/23. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The interim program specialist reviewed annual requirements for staff with the program coordinator on 3/26/24. The program coordinator reviewed annual staff requirements for staff with the direct staff on 3/26/24. 03/26/2024 Implemented
2380.39(c)(6)Program Specialist #2's annual training did not include the following training topic in the 2023 annual training year, dated 1/1/23 to 12/31/23: Implementation of the Individual Plan. Direct Support Professional #3's annual training did not include the following training topic in the 2023 annual training year, dated 1/1/23 to 12/31/23: Implementation of the Individual PlanThe 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.The CEO reviewed with the program specialist the annual training requirements on 3/26/24. The program specialist reviewed the annual training requirements with the program coordinator and direct staff on 3/26/24. On 3/26/24 the program coordinator created a training log for all staff working directly with an individual to fill out at the time of their Implementation of the ISP training. 03/26/2024 Implemented
2380.181(f)Program Specialist #1 completed Individual #1's assessment on 09/07/23; however, the assessment was not sent to the plan team prior to the individual plan meeting held on 10/25/23.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Upon further investigation, the former program specialist 2 discovered that program specialist 1 did indeed send individual 1's assessment at least 30 days prior to the individual plan meeting. The assessment was sent to individual 1's individual plan team on 9/08/23 via email. Email available and can be attached as proof. *Also, please note that the date on the Description is inaccurate-10/25/24. It was 2023. 09/07/2023 Implemented
SIN-00222310 Renewal 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(c)Direct Service Worker #1, date of hire 6/13/2022, had a Pennsylvania criminal history record check completed 3/09/2021.Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire.Because Staff 1's clearances were completed 15 months prior to hire, the program specialist will have staff 1 obtain new PA criminal history clearance and FBI criminal history clearances. Moving forward, the program specialist and coordinator will make sure prospective employees submit applications for PA and FBI clearances within 5 working days after employee's date of hire. Program coordinator and Program specialist will make sure the date of completion was no more than 12 months prior to staff's date of hire and will document the date completed on our new hire checklist. 04/06/2023 Implemented
2380.89(a)The first individual admitted to the program began receiving services on 9/27/2022, and the agency did not conduct fire drills in September 2022 nor October 2022.An unannounced fire drill shall be held at least once a month.Fire drill completion has been included on the intake checklist for all new admissions. 04/06/2023 Implemented
2380.91(a)Individual #1, date of admission 9/27/2022, was trained in fire safety 10/04/2022. Individual #2, date of admission 10/11/2022, was trained in fire safety 11/10/2022.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.Fire safety training will be conducted on the day of admission Fire safety training has been added to the new client initial checklist. 04/12/2023 Implemented
2380.21(u)Individual #1, date of admission 9/27/2022, was informed and explained individual rights 10/04/2022. Individual #2, date of admission 10/11/2022, was informed and explained individual rights 10/25/2022.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. 04/12/2023 Implemented
SIN-00203826 Renewal 04/20/2022 Compliant - Finalized
SIN-00203708 Initial review 04/18/2022 Compliant - Finalized