Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225138 Renewal 07/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's annual physical examination dated 1/4/23 did not include medical information pertinent 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.Program Specialist will review all physicals and return for completion to the physician if the medical information pertinent to diagnosis and treatment in case of an emergency is left blank. 08/01/2023 Implemented
2380.113(a)Staff #1's biannual physical examination was completed late. Staff #1 completed a physical examination on 1/8/20 and did not complete another physical examination until 2/15/22.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.Human Resources Department will forward staff physical dates/due dates to Supervisors, Program Directors and Program Specialists. as added layers of oversight. 08/01/2023 Implemented
SIN-00207193 Renewal 07/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1's physical exam dated 8/26/21 did not include a vision screening. This section of the physical exam was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.All consumer physicals shall be filled out completely with no blanks in any section. Each physical shall include a vision and hearing screening as recommended by the physician. Program Specialist shall review and ensure that all areas of physicals are complete when received. If any blanks are found physical shall be returned for completion by physician. 08/01/2022 Implemented
2380.111(c)(5)Individual #1 received Tuberculin skin testing with negative results on 8/22/19 and then not again until 9/9/21. This exceeds the requirement.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.Physical Examinations shall be completed every two years and will include Tuberculin tests showing negative results or, if the skin test was positive an initial chest X-ray with results noted. Program Specialist shall send a reminder to consumer or responsible individual two months prior to Physical Examination with Tuberculin testing expiration date and a second reminder one month prior to expiration date. . 08/01/2022 Implemented
SIN-00130499 Renewal 04/04/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #3 had a TB test on 1/12/2016. He didn't have another TB test until 3/5/2018, which exceeds the requirement.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.55 PA Code Chapter 2380.111(c)(5) All individuals shall have 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. Program specialist will review all physicals to insure compliance 05/01/2018 Implemented
2380.111(c)(7)Health maintenance needs was blank on Individual #1's physical exam dated 1/30/2018. On Individual #2's physical exam dated 8/10/2017, there was no section addressing the need for bloodwork.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.55 PA Code Chapter 2380.111(c)(7) All physicals shall include: An assessment of the individual's health maintenance needs, medication regimen, the need for blood work at recommended intervals and will not contain any blank areas. Program specialist will review all physicals when received and return if non-compliant. ((Individual #1's and Individual #2's physical will be update to include the missing information -CH 5/16/2018)) 05/01/2018 Implemented
2380.111(c)(10)This section was blank on Individual #1's physical exam dated 1/30/2018.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.55 PA Code Chapter 2380.111(c)(10) All physicals shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program specialist will review physicals when received and return if non-compliant. ((Individual #1's physical will be updated to include the missing information -CH 5/16/18)) 05/01/2018 Implemented
2380.173(1)(ii)Identifying marks were not listed in Individual #1's record.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.55 PA Code Chapter 2380.173(1)(ii) Each individual record will be reviewed by program specialist to ensure any and all identifying marks are outlined. 05/01/2018 Implemented
2380.181(a)Individual #4 had an assessment completed on 6/6/2016. She didn't have another assessment completed until 6/22/2017, which exceeds the annual requirement.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.55 PA Code Chapter 2380.181(a) All individuals will have an initial assessment within 60 calendar days after admission and annually thereafter by program specialist. ((Program Specialist will be trained in the requirement of this regulations -CH 5/16/2018)) 05/01/2018 Implemented
2380.181(e)(12)There were no recommendations in the assessments for Individual #2, Individual #3, Individual #4, and Individual #5.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.55 PA Code Chapter 2380.181(e)(12) All assessments will be revised by program director to include recommendations for specific areas of training, vocational programming and competitive community integrated employment. 05/01/2018 Implemented
2380.186(a)Individual #4 had an ISP Review on 7/25/2017. She didn't have another ISP Review until 1/17/2018, which exceeds the 3 month requirement.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.55 PA Code Chapter 2380.186(e) ISP reviews of services and expected outcomes shall be completed every three months or sooner by the program specialist if individual needs change which impact services specified in the current ISP. ((Program Specialist will receive training on the requirements of this regulation -CH 5/16/2018)) 05/01/2018 Implemented
SIN-00092191 Renewal 05/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 was admitted to the program on 10/20/2015. She didn't have a TB test until 2/8/2016; there was no previous TB test on record. Individual #2 was admitted to program on 10/15/2015. He didn't have a TB test until 1/6/2016; there was no previous TB test on record. 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.All individuals will have a physical examination which shall include -tuberculin skin testing with negative results every 2 years; or, if the skin test is positive, an initial chest x-ray with results noted, prior to admittance to the program and every 2 years thereafter. Documentation has been received clarifying Individual #2 received tuberculin testing on 6/2/14 with negative results reported.ATF consumer medical records will be reviewed on a monthly basis by Program Specialist to ensure TB testing is in accordance with regulations. Reminders will be issued prior to due date to further ensure compliance 05/06/2016 Implemented
SIN-00075669 Renewal 04/28/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)The fire safety training for Staff #1 was last completed on 3/12/2014. As of April 28, 2015, staff #1 has not completed her annual fire safety training. Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).All staff will receive fire safety training annually. Staff #1 received training on 4/29/2015 - copy provided. The Training Coordinator will track the fire safety trainings. 04/29/2015 Implemented
2380.62No emergency telephone list was posted near the telephone in the conference/board room. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.Emergency telephone numbers have been posted on each telephone throughout the facility - photo provided. The Director of Operations/Quality Assurance will continue to monitor the emergency telephone lists every 6 months. 04/29/2015 Implemented
2380.113(a)Staff #1 received her physical on 1/18/2012 and on 2/10/2014.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.All staff will have complete physical & Mantoux test every 2 years. The Human Resources Department will track and monitor the staff physicals. 05/01/2015 Implemented
SIN-00247823 Renewal 07/02/2024 Compliant - Finalized
SIN-00189186 Renewal 07/06/2021 Compliant - Finalized
SIN-00154042 Renewal 04/04/2019 Compliant - Finalized
SIN-00112765 Renewal 05/30/2017 Compliant - Finalized
SIN-00086673 Change in Location Capacity 11/20/2015 Compliant - Finalized
SIN-00059170 Renewal 03/21/2014 Compliant - Finalized