Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285613 Renewal 03/24/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)A fire drill was held on 9/8/2025 and then again on 2/19/2026.A fire drill shall be held at least every 90 calendar days. A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.The missed fire drill was to occur prior to Dec, 30, 2025 and we have subsequently completed a fire drill in February 2026. Our plan of correction will be to complete a fire drill by April 30th, 2026 and within every 90 days moving forward. As an organization, our leadership group and compliance team have already met on March 26, 2026 to review the results of the audit and address the issue with the missed fire drill. 04/30/2026 Implemented
2390.151(e)(2)Individual #4's assessment, completed 4/10/2025, did not include the individual's dislikes. Individual #5's assessment, completed 4/9/2025, did not include the individual's dislikes.The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client.The Program Specialist will add an addendum to the assessment to include the client's dislikes in the most recent annual assessment. Moving forward, dislikes will be included in client annual assessments. Refresher training for program specialist team on assessment requirements. 04/30/2026 Implemented
2390.151(e)(9)Individual #2's assessment, completed 10/3/2025, did not include documentation of disability including functional and medical limitations. The assessment stated, "See case file" next to documentation of disability. Individual #3's assessment, completed 6/5/2025, did not include documentation of disability including functional and medical limitations. The assessment stated, "See case file" next to documentation of disability. Individual #4's assessment, completed 4/10/2025, did not include documentation of disability including functional and medical limitations. The assessment stated, "See case file" next to documentation of disability. Individual #5's assessment, completed 4/9/2025, did not include documentation of disability including functional and medical limitations. The assessment stated, "See case file" next to documentation of disability.The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations.We will update the client information sheet, which includes documentation of the client's disability and any functional and/or medical limitations of the client. This will be included in the annual assessment to represent the client's documentation of disability. The current individual case files will be updated with the appropriate information for clients #2, #3, #4 and #5. Refresher training with program specialist team on assessment requirements. 04/30/2026 Implemented
2390.151(e)(10)Individual #2's assessment, completed 10/3/2025, did not include a lifetime medical history. The assessment stated, "See case file." Individual #3's assessment, completed 6/5/2025, did not include a lifetime medical history. The assessment stated, "See case file." Individual #4's assessment, completed 4/10/2025, did not include a lifetime medical history. The assessment stated, "See case file." Individual #5's assessment, completed 4/9/2025, did not include a lifetime medical history. The assessment stated, "See case file."The assessment must include the following information: A lifetime medical history.We will add an addendum to the file that includes the information regarding lifetime medical history. Moving forward, the most recent client physical that Life'sWork has on record will be included in the annual assessment to represent the client's lifetime medical history. 04/30/2026 Implemented
2390.151(e)(12)Individual #2's assessment, completed 10/3/2025, did not include recommendations for specific areas of vocational training or placement and competitive community-integrated employment. This section stated, "Need to change service: No. This individual is able to be competitively employed: No." Individual #3's assessment, completed 6/5/2025, did not include recommendations for specific areas of vocational training or placement and competitive community-integrated employment. This section stated, "Need to change service: No. This individual is able to be competitively employed: No." Individual #4's assessment, completed 4/10/2025, did not include recommendations for specific areas of vocational training or placement and competitive community-integrated employment. This section stated, "Need to change service: No. This individual is able to be competitively employed: No." Individual #5's assessment, completed 4/9/2025, did not include recommendations for specific areas of vocational training or placement and competitive community-integrated employment. This section stated, "Need to change service: No. This individual is able to be competitively employed: No."The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.The individual records for individuals will be amended to include the vocational training or placement and competitive community-integrated employment. Refresher training with program specialist team regarding content required for assessments. The Life'sWork Annual Assessment template will be amended to include a narrative section for individualized recommendations for specific areas of vocational training to support community based employment. Moving forward, all client annual assessments will include a narrative section of individualized recommendations for specific areas of vocational training to support community-based employment. 04/30/2026 Implemented
2390.21(u)Individual #5 was informed of and explained individual rights on 3/11/2025 and then again on 3/12/2026. Individual #6 was informed of and explained individual rights on 3/11/2025 and then again on 3/12/2026. Individual #6 was informed of and explained individual rights on 3/11/2025 and then again on 3/12/2026.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Refresher training with program specialists regarding the regulation and guidelines regarding client rights timelines. The training will cover the expectation that program specialists will explain client rights and the process to report a rights violation to the client, and persons designated by the client, upon admission and on an annual basis. 04/30/2026 Implemented
2390.40(a)The orientation training record for Direct Service Worker #2's, date of hire 12/5/2025, did not include a date.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Complete records review and enter date training was completed. Refresher training with Human Resources + Hiring Managers regarding training record requirements and need to include all necessary information and to be completed within timeframes outlined. 04/30/2026 Implemented
2390.48(a)(3)Direct Service Worker #2's, date of hire 12/5/2025, orientation training did not include a date; therefore, compliance for timeliness could not be measured. Direct Service Worker #3, date of hire 12/5/2025, completed orientation training on 3/24/2026.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.Re-train Hiring Managers and Human Resources team regarding the orientation and onboarding requirements for all staff to include the completion of the training and the timelines expected. Create an orientating tracking form for all new hires to be used to track and maintain compliance. 04/30/2026 Implemented
2390.124(1)Individual #1's record did not include the individual's birthplace.Each client's record must include the following information: The name, sex, admission date, birthdate and place, Social Security number and dates of entry, transfer and discharge.For individual #1, the birthplace will be added to this client's record. Refresher training for program specialist team regarding record requirements. 04/30/2026 Implemented
2390.151(f)Program Specialist #1 provided Individual #2's assessment, completed 10/3/2025, to the plan team members on 10/27/2025 for the individual plan meeting on 11/24/2025.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Complete a refresher training with program specialist team regarding requirements for sending information to team member at least 30 days prior to the individual meeting. Moving forward, the program specialists will send annual assessments to the individual's team at least 30 calendar days prior to the individual plan meeting. 04/30/2026 Implemented
SIN-00264218 Renewal 04/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1, date of hire 08/26/24, did not have an initial assessment completed until 01/20/25. This exceeds 60 calendar days after admission to the facility.Each client 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.Moving forward, all new clients to Life'sWork Facility 0011 will have an initial assessment within 1 year prior or 60 calendar days after admission to the facility that is conducting by the Program Specialist. Individual #1 had a career assessment completed by Life'sWork staff while under facility 0012 that was end dated 5/28/2024. 04/17/2025 Implemented
2390.151(e)(5)Individual #1's assessment completed 01/20/25 indicated in the ability to self-administer medications section "did not take medications throughout the program assessment." Individual #2's assessment completed 12/5/24 indicated in the self-administration of medication section "Not assessed, [Individual #2] does not take medication at work". Individual #3's assessment completed 1/2/25 did not address the ability to self-administer medications. This section was not included in Individual #3's assessment. Individual #4's assessment completed 11/6/24 indicated in the self-administration of medication section "[Individual #4] does not take medication at work". The assessment must include the following information: The client's ability to self-administer medications.Life'sWork Program Specialists will review all current client assessments to determine which clients may still need to be assessed by Life'sWork staff for their ability to self-administer medication. The Program Specialist will then collaborate with the necessary clients and teams to assess the client's ability to self- administer medications. After the assessment has occurred, the Program Specialist will add an addendum to the assessment with the necessary self-administration of medication assessment information. Moving forward, the client's ability to self-administer medications will be assessed by the Program Specialist, in collaboration with the client and team, and included in all annual assessments. 04/17/2025 Implemented
2390.151(e)(6)Individual #2's assessment completed 12/5/24 indicated in the Poison safe section "[Individual #2] does not work near poisonous chemicals. An all-purpose liquid cleaner is in a locked box." Individual #4's assessment completed 11/6/24 indicated in the Poison safe section "[Individual #4] does not work near poisonous chemicals. An all-purpose liquid cleaner is in a locked box." The assessment must include the following information: The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Life'sWork Program Specialists will review all current client assessments to determine which clients may still need to be assessed by Life'sWork staff for their ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Program specialists will then collaborate with the necessary clients and teams to assess their ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. After the assessment has occurred, the Program Specialists will add an addendum to the assessment with the necessary information pertaining to their ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Moving forward, the client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials, will be assessed by the Program Specialist, in collaboration with the client and team, and included in all annual assessments. 04/17/2025 Implemented
SIN-00243347 Renewal 04/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.48(b)(4)Direct Service Worker #1, date of hire 7/11/2023, completed the recognizing and reporting incidents orientation training on 8/17/2023. This exceeds the requirement the orientation training topics be completed within 30 days of hire, as required by 2390.48(a).The orientation must encompass the following areas: Recognizing and reporting incident.The direct service worker completed the recognizing and reporting incident training, however it was outside of the 30 day orientation window. All new staff members will complete the required orientation training within the 30 day orientation period. 05/09/2023 Implemented
SIN-00224492 Renewal 05/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Direct Service Worker #2 was instructed in general fire safety and the use of fire extinguishers on 3/17/22 and then again on 5/9/23. Direct Service Worker #3 was instructed in general fire safety and the use of fire extinguishers on 3/17/22 and then again on 5/9/23.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.All new staff hired, and clients as appropriate, will be instructed on general fire safety and in the use of fire extinguishers. This training will be conducted by the Human Resources department and coordinated with the initial onboarding process. Annual fire training will be provided to all team members by the organization within 365 days of the previous training date. Staff members #2 and #3 who were in violation completed the training on 5/9/23 05/09/2023 Implemented
2390.49(c)(1)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #1 did not encompass community integration, client choice, and supporting clients to develop and maintain relationships. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #2 did not encompass person centered practices, community integration, client choice, and supporting clients to develop and maintain relationships. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass person centered practices, community integration, client choice, and supporting clients to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.The organization will create a training presentation that encompasses all of the requirements as it pertains to person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships. The 6100 Regulation Training will cover all necessary information to ensure compliance with the application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships. Staff member #1 completed the required trainings on 6/26/22 Staff member #2 completed the required trainings on 3/3/22, 5/11/22, 9/30/22, 12/5/22, 3/26/23 06/07/2023 Implemented
2390.49(c)(2)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #1 did not encompass prevention, detection, and reporting of abuse. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #2 did not encompass prevention, detection, and reporting of abuse. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass prevention, detection, and reporting of 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.The organization will create a training presentation that encompasses all of the requirements as it pertains to 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. The 6100 Regulation Training will cover all necessary information to ensure compliance with 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. Staff member #1 completed training on 6/7/23 06/07/2023 Implemented
2390.49(c)(3)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass Individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.The organization will create a training presentation that encompasses all of the requirements as it pertains to Client Rights. The 6100 Regulation Training will cover all necessary information to ensure compliance with Client Rights. Staff member #3 completed this training on 6/5/23. 06/05/2023 Implemented
2390.49(c)(4)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass recognizing and reporting incidents. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #4 did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The organization will create a training presentation that encompasses all of the requirements as it pertains to Recognizing and Reporting Incidents. The 6100 Regulation Training will cover all necessary information to ensure compliance with Recognizing and Reporting Incidents. Staff member #3 completed this training on 5/25/23 Staff member #4 completed this training on 12/7/22 06/07/2023 Implemented
2390.49(c)(5)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #4 did not encompass 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 a client.The organization will create a training presentation that encompasses all of the requirements as it pertains to Behavior Supports. The 6100 Regulation Training will cover all necessary information to ensure compliance with Behavior Supports. Staff member #4 completed this training on 4/13/23 06/07/2023 Implemented
2390.49(c)(6)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #4 did not encompass 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 a client.The team members who directly work with a client will be responsible to review the ISP of each individual that they work with during their job. The list of clients to be reviewed will be provided by the Program Specialist and the direct support professional and program specialist will work together to ensure that each plan is reviewed and accounted for during the training year. Staff member #4 completed this training on 6/5/23 06/05/2023 Implemented
SIN-00206883 Renewal 06/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Direct Service Worker #1, date of hire 8/16/2021, was instructed in general fire safety on 3/17/2022. Direct Service Worker #2, date of hire 8/02/2021, was instructed in general fire safety on 4/19/2022.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.All new staff hired, and clients as appropriate, will be instructed on general fire safety and in the use of fire extinguishers. This training will be conducted by the Human Resources department and coordinated with the initial onboarding process. Annual training will be provided to all team members by the organization. 07/01/2022 Implemented
2390.48(a)(3)Direct Service Worker #1, date of hire 8/16/2021, has no record of completing an orientation training. Direct Service Worker #2, date of hire 8/02/2021, has no record of completing an orientation training.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.Provider's Plan of Correction: Provide documentation of completed Orientation Training by direct service #1 and #2. 07/01/2022 Implemented
SIN-00187397 Renewal 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)-2The written record for the fire drill held on 3/4/2021 does not include the hypothetical location of the fire drill.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.On August 10, 2020 our program moved from our previous location at 1323 Forbes avenue, which we owned, to our current location at 2403 Sidney Street in the Southside, which we lease. Since we are now leasing, our maintenance director no longer coordinates fire drills and thus the form was not fully completed. On May 24, 2021 the Director of Facilities & Corporate Secretary, Director of Business Services, and the Director of Client Services reviewed our fire drill procedure to ensure that the form will be completed properly including the hypothetical location. 05/24/2021 Implemented
2390.87Chief Executive Officer #1 was instructed in general fire safety and in the use of fire extinguishers most recently on 4/9/2019. Program Specialist #2 was instructed in general fire safety and in the use of fire extinguishers on 3/27/19 and again on 5/10/2021.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Due to mandated closures from the pandemic, Life¿sWork did not conduct a fire safety training for the staff in 2020. We do realize that we should have conducted a training once the facility opened back up. The Director of Client Services will ensure that the Chief Executive Officer will complete the fire safety training by 6/30/2021. 06/30/2021 Implemented
2390.49(c)(2)The annual training hours for the training year from 7/1/2019 to 6/30/2020 for Chief Executive Officer #1, Program Specialist #2, Direct Service Worker #3 and Program Specialist #4 did not encompass 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.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.The detection and reporting of abuse is typically reviewed during our incident management training. However, due to the scope of the trainings available through the myodp website, the Director of Client Services will ensure that all staff take those trainings, which will be completed by 6/30/2021. 06/30/2021 Implemented
2390.49(c)(3)The annual training hours for the training year from 7/1/2019 to 6/30/2020 for Chief Executive Officer #1 and Program Specialist #2's did not encompass client Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Program Specialist #2 did complete the training on client rights on May 3, 2021. The certificate from the training will be submitted as proof. The Director of Client Services will ensure that the Chief Executive Officer will receive the training by 6/30/2021. [Certificate of achievement for Program Specialist #2 was provided to the Department on 5/26/21.] 06/30/2021 Implemented
2390.49(c)(4)The annual training hours for the training year from 7/1/2019 to 6/30/2020 for Chief Executive Officer #1 did not encompass recognizing and reporting Incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The Director of Client Services will ensure that the Chief Executive Officer will complete the training on Recognizing and Reporting Incidents by 6/30/2021. 06/30/2021 Implemented
SIN-00174457 Initial review 07/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.59The telephone numbers of the nearest police department, fire department and ambulance were not posted by the telephone in the office area.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneTelephone numbers of the nearest police department, fire department and ambulance service will be posted by the phones on Thursday, August 6, 2020 by Chris Phelps, Director of Client Services. A picture of the posted numbers will be sent to Amy Scharpf. [Photo of telephone with required telephone numbers submitted to and received by the Department. Upon admission and hire, all staff and individuals will be educated on the location and use of the telephone system and the posted telephone numbers. At least quarterly, a designated staff person shall check to ensure required telephone numbers continue to be posted by all telephones in the facility. (DPOC by AES,HSLS on 8/6/20)] 08/06/2020 Implemented
2390.75(b)(2)The dining area did not have chairs.A facility shall have a dining area for lunches and breaks. The area shall be clean and have dining tables and chairs. The dining area shall have a sufficient number of tables and chairs to accommodate the maximum number of clients scheduled for lunch or break.The dining area now has chairs. Pictures of the dining area with chairs was sent to Amy Scharpf by Chris Phelps, Director of Client Services, on Tuesday, August 4, 2020. [Photos of chairs submitted to and received by the Department. At least quarterly, a designated staff person shall check to ensure dining areas are clean and have tables and chairs sufficient to accommodate the clients for lunch and breaks. (DPOC by AES,HSLS on 8/6/20)] 08/04/2020 Implemented
2390.82(a)The written emergency evacuation diagram specifying directions for egress in the event of an emergency was not posted in the work area.Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.Three emergency evacuation diagrams specifying directions for egress in the event of an emergency were posted in the work area. Pictures of the posted diagrams were sent to Amy Scharpf by Chris Phelps, Director of Client Services, on Tuesday, August 4, 2020. [Photos of evacuation routes submitted to and received by the Department. Upon admission and hire, all staff and individuals will be educated on the location of the evacuation routes and the written emergency evacuation procedures including the evacuation diagram specifying directions for egress in the event of an emergency. At least quarterly, a designated staff person shall check to ensure evacuation routes are posted as required. (DPOC by AES,HSLS on 8/6/20)] 08/04/2020 Implemented
2390.193(d)The first aid kit contained a variety of single packet medications including but not limited to: Bayer aspirin, Aleve, Day Quill, Mucinex, cough Drops, acetaminophen and ibuprofen. In addition, the agency's medication policy stated medications were not administered.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The medications have been removed from the first aid kit. A picture of the first aid kit without the medications was sent to Amy Scharpf by Chris Phelps, Director of Client Services, on Tuesday, August 4, 2020. [Photos of first aid kit submitted to and received by the Department. Upon hire, all staff shall be educated on the location of the first aid kit and the facilities medication administration procedures. At least quarterly, a designated staff person shall check the first aid kit to ensure all required items are present and there are not unlocked medications. (DPOC by AES,HSLS on 8/6/20)] 08/04/2020 Implemented