Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286542 Renewal 04/09/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(c)Program Specialist #1, date of hire of 7/1/25 had a criminal history record check completed on 6/1/23.Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire.This occurred due to Program Specialist #2 overlooking the year on the background check. Program Specialist #1 requested a new background check to be completed and received it on 4/17/2026. Program Specialist #1 will create a new hire document checklist that details what documents are needed prior to the start date and that the content of them are correct. Program Specialist #1 will review new hire paperwork within the last year and ensure compliance as the director is on leave, no later than 4/30/226. Director will review as well upon her return from leave no later than 5/15/2026. 05/15/2026 Implemented
2380.111(c)(4)The physical examination completed 12/4/25 for Individual #3, date of admission 2/5/26 did not include a full hearing examination, only the left ear was examined. The physical examination completed 12/4/25 for Individual #3 did not include a vision examination. Individual #3, date of admission 2/5/26 had a vision examination completed on 4/6/26.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialist #1 did not properly review physical paperwork received by individual #3. Program Specialist #1 will work with individual #3's SC to correct any mistakes or missing items in the physical. Program Specialist #1 met with the SC 4/23/26 to discuss what still needed fixed. SC will be reaching out the individual #3's doctor's office and Program Specialist #1 followed up via email on 4/29/26 to see if the SC heard back from the doctor and will continue to work with the SC until all aspects of the physical are properly filled out. This is to be completed by 5/15/2026. Program Specialist #1 will review chapter 2380.111(c)(1-11) and create a review checklist that details all physical requirements and use the checklist to ensure each item needed is properly documented. Program Specialist #1 will use this checklist to review all current client physicals to check for mistakes and/or missing information and ensure that the information is being implemented to provide each client the care they require. Current client physicals will be reviewed by 4/27/26. 05/15/2026 Implemented
2380.111(c)(5)Individual #3 had a tuberculin skin test placed on 10/4/25; however, there is no documentation of the results of Individual #3's testing.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.Program Specialist #1 did not properly review physical paperwork received by individual #3. Program Specialist #1 worked with individual #3's SC to correct this and received the proper paperwork 4/16/26. Program Specialist #1 will review chapter 2380.111(c)(1-11) and create a review checklist that details all physical requirements and use the checklist to ensure each item needed is properly documented. Program Specialist #1 will use this checklist to review all current client physicals to check for mistakes and/or missing information and ensure that the information is being implemented to provide each client the care they require. Current client physicals will be reviewed by 4/27/26. 05/15/2026 Implemented
2380.111(c)(7)Individual #3's physical examination, completed 12/4/25 did not include an assessment of Individual #3's health maintenance needs, medication regimen and the need for blood work at recommended intervals.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 #1 did not properly review physical paperwork received by individual #3. Program Specialist #1 will work with individual #3's SC to correct any mistakes or missing items in the physical. Program Specialist #1 met with the SC 4/23/26 to discuss what still needed fixed. SC will be reaching out the individual #3's doctor's office and Program Specialist #1 followed up via email on 4/29/26 to see if the SC heard back from the doctor and will continue to work with the SC until all aspects of the physical are properly filled out. This is to be completed by 5/15/2026. Program Specialist #1 will review chapter 2380.111(c)(1-11) and create a review checklist that details all physical requirements and use the checklist to ensure each item needed is properly documented. Program Specialist #1 will use this checklist to review all current client physicals to check for mistakes and/or missing information and ensure that the information is being implemented to provide each client the care they require. Current client physicals will be reviewed by 4/27/26. 05/15/2026 Implemented
2380.111(c)(8)Individual #3's physical examination, completed on 12/4/25 did not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual.Program Specialist #1 did not properly review physical paperwork received by individual #3. Program Specialist #1 will work with individual #3's SC to correct any mistakes or missing items in the physical. Program Specialist #1 met with the SC 4/23/26 to discuss what still needed fixed. SC will be reaching out the individual #3's doctor's office and Program Specialist #1 followed up via email on 4/29/26 to see if the SC heard back from the doctor and will continue to work with the SC until all aspects of the physical are properly filled out. This is to be completed by 5/15/2026. Program Specialist #1 will review chapter 2380.111(c)(1-11) and create a review checklist that details all physical requirements and use the checklist to ensure each item needed is properly documented. Program Specialist #1 will use this checklist to review all current client physicals to check for mistakes and/or missing information and ensure that the information is being implemented to provide each client the care they require. Current client physicals will be reviewed by 4/27/26. 05/15/2026 Implemented
2380.111(c)(9)Individual #3's physical examination, completed 12/4/25 did not include allergies or contraindicated medication.The physical examination shall include: Allergies or contraindicated medication.Program Specialist #1 did not properly review physical paperwork received by individual #3. Program Specialist #1 will work with individual #3's SC to correct any mistakes or missing items in the physical. Program Specialist #1 met with the SC 4/23/26 to discuss what still needed fixed. SC will be reaching out the individual #3's doctor's office and Program Specialist #1 followed up via email on 4/29/26 to see if the SC heard back from the doctor and will continue to work with the SC until all aspects of the physical are properly filled out. This is to be completed by 5/15/2026. Program Specialist #1 will review chapter 2380.111(c)(1-11) and create a review checklist that details all physical requirements and use the checklist to ensure each item needed is properly documented. Program Specialist #1 will use this checklist to review all current client physicals to check for mistakes and/or missing information and ensure that the information is being implemented to provide each client the care they require. Current client physicals will be reviewed by 4/27/26. 05/15/2026 Implemented
2380.111(c)(10)Individual #3's physical examination, completed 12/4/25 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist #1 did not properly review physical paperwork received by individual #3. Program Specialist #1 will work with individual #3's SC to correct any mistakes or missing items in the physical. Program Specialist #1 met with the SC 4/23/26 to discuss what still needed fixed. SC will be reaching out the individual #3's doctor's office and Program Specialist #1 followed up via email on 4/29/26 to see if the SC heard back from the doctor and will continue to work with the SC until all aspects of the physical are properly filled out. This is to be completed by 5/15/2026. Program Specialist #1 will review chapter 2380.111(c)(1-11) and create a review checklist that details all physical requirements and use the checklist to ensure each item needed is properly documented. Program Specialist #1 will use this checklist to review all current client physicals to check for mistakes and/or missing information and ensure that the information is being implemented to provide each client the care they require. Current client physicals will be reviewed by 4/27/26. 05/15/2026 Implemented
2380.111(c)(11)Individual #3's physical examination, completed 12/4/25 did not include special instructions for an individual's diet.The physical examination shall include: Special instructions for an individual's diet.Program Specialist #1 did not properly review physical paperwork received by individual #3. Program Specialist #1 will work with individual #3's SC to correct any mistakes or missing items in the physical. Program Specialist #1 met with the SC 4/23/26 to discuss what still needed fixed. SC will be reaching out the individual #3's doctor's office and Program Specialist #1 followed up via email on 4/29/26 to see if the SC heard back from the doctor and will continue to work with the SC until all aspects of the physical are properly filled out. This is to be completed by 5/15/2026. Program Specialist #1 will review chapter 2380.111(c)(1-11) and create a review checklist that details all physical requirements and use the checklist to ensure each item needed is properly documented. Program Specialist #1 will use this checklist to review all current client physicals to check for mistakes and/or missing information and ensure that the information is being implemented to provide each client the care they require. Current client physicals will be reviewed by 4/27/26. 05/15/2026 Implemented
2380.113(a)Program Specialist #1, date of hire of 7/1/25 had a physical examination completed on 7/2/25.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 Specialist #2 overlooked this as Program Specialist #1 was not in contact with individuals for two weeks following the start date. Program Specialist #1 will create a new hire document checklist that details what documents are needed prior to the start date and that the content of them are correct. Program Specialist #1 will review new hire paperwork within the last year and ensure compliance as the director is on leave, no later than 4/30/26. Director will review as well upon her return from leave no later than 5/15/2026. 05/15/2026 Implemented
2380.181(a)Individual #1 had an assessment completed on 6/27/24 and then again 2/17/26.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.Due to Individual #1 change of guardianship during this time, Program Specialist #2 was advised to update the assessment early and that she could do so by adding the new date and her initials. Program Specialist #2 overlooked that an entire new assessment would need to be competed as well. Program Specialist #1 will review 2380.181(a) by 4/17/2026. Program Specialist #1 will review all client assessments to ensure they are currently up to date, no later than 4/30/2026. Program Specialist #1 will set up a system using Outlook to track and send a reminder 30 days before the assessment is due for every client. This will be completed by 4/30/2026. Program Specialist #1 and Director will review 2380.181(a) together, to ensure both parties understand the importance of this regulation. 05/15/2026 Implemented
2380.181(e)(5)Individual #3's initial assessment, completed 4/6/26 has a section for the individual's ability to self-administer medication which was answered, "Yes, see self-administration questionnaire." Individual #3's Individual plan, last updated on 2/16/26, states that Individual #3 is unable to self-administer Citalopram. Individual #4's assessment completed 3/20/26 has a section for the individual's ability to self-administer medication which was answered, "Yes, see self-administration questionnaire." Individual #4's individual plan, last updated on 4/8/26, states that Individual #4 is unable to self-administer Citalopram and Melatonin.The assessment must include the following information: The individual¿s ability to self-administer medications.Program Specialist #1 did not properly review individuals #3 and #4 medication section in their individual plans. Program Specialist #1 will correct these in the assessments and review the other individuals assessments to correct any mistakes found. This will be completed by 4/24/2026.Program Specialist #1 will review 2380.181(e)(5) along with the rest of 2380.181 by 4/24/2026 and continue to do so each time an assessment is completed. 05/15/2026 Implemented
2380.181(e)(10)Individual #3's initial assessment, completed 4/6/26 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.Program Specialist #1 overlooked this when reviewing individual #3's medical information. Program Specialist #1 will create a lifetime medical history starting at individual #3's admission date. This will be completed by 4/30/26 and will be updated quarterly. Program Specialist #1 will review all individuals lifetime medical histories to ensure they are up to date. 04/30/2026 Implemented
2380.181(e)(12)In the recommendations for specific areas of training, vocational programming and competitive community-integrated employment section of Individual #1's assessment, completed 2/17/26 reads, "[Individual #1] does not have any interest." In the recommendations for specific areas of training, vocational programming and competitive community-integrated employment section of Individual #2's assessment, completed 1/6/26 reads, "not applicable." In the recommendations for specific areas of training, vocational programming and competitive community-integrated employment section of Individual #4's assessment completed 3/20/26 reads, "not applicable."The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Program Specialist #1 overlooked the need to complete this section due to individuals #1, #2, and #4 not having an interest in specific areas of training, vocational programming and competitive community-integrated employment. Program Specialist #1 will correct these in the assessments of individuals #1, #2, and #4 as well as review this section of the assessment for all other individuals. This will be completed by 4/24/2026. 05/15/2026 Implemented
2380.36(b)Program Specialist #2 was trained in general fire safety on 4/12/24 and then again on 4/15/25.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program Specialist #2 overlooked this needing done and completed it as soon as the mistake was found. Program Specialist #1 will create a reminder in Outlook that notifies the program specialist and the staff member 30 days before their training is due. These reminders will be completed for each staff member by 5/1/2026. 05/01/2026 Implemented