Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00269546 Renewal 07/21/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(c)The Inoperative Alarm Repairs (Fire Bell Malfunction) policy does not state arrangements for repair will be made within 24 hours and repairs completed within 4 working days of the time fire alarm was found to be inoperative.If the fire alarm is inoperative, arrangements for repair shall be made within 24 hours and the repairs completed within 4 working days of the time the fire alarm was found to be inoperative.The Fire Bell Malfunction policy was updated, on 8/4/25. Policy now states that "If the fire alarm is inoperative, arrangements for repair shall be requested from the building owner, immediately. Building owner will be asked to make arrangements for repair within 24 hours of discovery and that repairs are completed within 4 working days of the time the fire alarm was found to be inoperative. 08/06/2025 Implemented
2380.113(c)(3)The Immunizations section of Individual #1's physical exam form completed 3/7/2025 was left blank.The physical examination shall include: A signed statement that the person is free of serious communicable diseases 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, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.The immunizations section of individual #1's physical exam form was updated to include the individual's immunizations. The immunizations were included (PCP visit 6/24/25) in the medical section of the individual's file but were separate from the EARS physical completed on 3/7/25. The immunization list is quite lengthy and requires more space than the immunization section of the physical form allows. The program specialist numbered the pages of the physical and additional documentation from the PCP and references the appropriate page numbers in the immunization section (7/23/25). 08/06/2025 Implemented
SIN-00248099 Renewal 07/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.177Individual #3's release of information dated 6/25/2018 did not contain all team members who had received information related to the individual.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.The release of information was updated on 7/18/24 (see attachment 2380.177), to include all members of the individual's team. 07/22/2024 Implemented
SIN-00228819 Renewal 09/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The Hillyard Antibacterial soap in the bathroom soap dispensers is a poisonous material.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Non-toxic soap was purchased, on 9/20/23 and placed in the soap dispensers. See purchase order (attachment 1) and pictures of the new soap with ingredients (attachment 2). 09/21/2023 Implemented
2380.113(a)Staff # 1 received a physical examination on 11/10/20 and not again until 12/01/22. Staff physicals are required every two years.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.Staff #1 had their physical scheduled in a timely manner. The day that the TB test was to be read, the staff person was sick. They contacted their PCP's office and was asked to not come into the office while sick. Staff #1 had to schedule an appointment to have the TB test placed a second time which caused the physical to be completed late. Staff #1 contacted the PCP to request documentation stating why the physical was not completed on time. The PCP was not able to provide the documentation. 10/06/2023 Implemented
2380.113(c)(2)Staff # 1 received a TB test on 11/12/20 and not again until 01/25/23. Tuberculosis tests are required every two years.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.Staff #1 had their physical scheduled in a timely manner. The day that the TB test was to be read, the staff person was sick. They contacted their PCP's office and was asked to not come into the office while sick. Staff #1 had to schedule an appointment to have the TB test placed a second time which caused the physical to be completed late. Staff #1 contacted the PCP to request documentation stating why the physical was not completed on time. The PCP was not able to provide the documentation. 10/06/2023 Implemented
2380.39(c)(5)Staff # 1 did not receive training in positive behavioral supports during the 06/2021-07/2022 training year.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.This non-compliance was discovered during our QA&I process in August 2022. We made the correction and trained all staff in September 2022, including Staff #1. 09/28/2022 Implemented
SIN-00210306 Renewal 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Comet cleaner with bleach was found above the kitchen sink in the conference room unlocked.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The Comet was removed from the cabinet, during the inspection, and placed in the appropriate locked closet. 09/06/2022 Implemented
2380.111(b)Individual #2's 10/1/2020 current PPD was read by a medical assistant. Individual #3's 7/28/2021 current PPD was read by a medical assistant.The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.Individual #2 had a physical exam already scheduled for 9/10/22. The program specialist for Individual #2 called their mother and explained the requirement to her. They also sent a written reminder, along with a new physical form, which prompts the medical provider to have a physician, SNP, or PA, read the TB test. (Attachments are labeled with the regulation number). 09/10/2022 Implemented
2380.113(c)(2)Staff # 3's PPD test dated 10/08/21 was read by a Certified Medical Assistant and not an RN, LPN, Licensed physician, Certified Nurse Practitioner or Licensed Physicians Assistant.. Staff #2's PPD was read by a medical assistant 7/3/2020 and 5/16/22.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.Staff #2 had a new PPD test administered on 9/6/22 and read on 9/8/22. Staff #3 had a new PPD test administered on 9/9/22 and read on 9/12/22. They were signed by a CRNP for Staff #2 and a physician for Staff #3. Neither staff worked in the facility or with individuals until the new PPDs could be administered and read. 09/12/2022 Implemented
SIN-00176695 Renewal 09/22/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62There were no emergency phone numbers located on the phone in the life skills 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.2380 Supervisor, ., added a label to the phone on 9/24/20 (Attachments 1 & 2). The label includes the numbers for the nearest hospital, police department, fire department, ambulance, and poison control center. This non-compliance occurred as a result of a corded phone being replaced with a hand-set phone. The numbers were posted on the wall and not replaced with a label on the hand-set. This regulation was reviewed with the Management Team, which includes a supervisor from each department, including maintenance, on 9/29/20 (Pages 5 & 6). Department supervisors will be responsible for ensuring that all phones, in their department, have labels (for hand-sets) or laminated cards (for corded phones). 09/29/2020 Implemented
2380.89(e)From September 2019 until September 2020, it is documented on the fire drill logs that the exit used was the "primary" exit (the front door exit) and an alternate exit route was not used in the past licensing year.Alternate exit routes shall be used during fire drills.A fire drill, utilizing the alternate evacuation route, was held on 10/7/20 (Page 7). Every individual evacuated within the allotted time. This non-compliance was discussed at the Management Meeting held on 9/29/20 (Page 5 & 6). Supervisors from every department were in attendance. A fire drill, utilizing the alternate route, will be held once per quarter. 10/07/2020 Implemented
2380.126(a)(3)The Medication Administration Records for individual #2 states that he has "No Known Allergies" however, individual #2's most recent physical dated 3/11/2020 states that the individual is allergic to "Ceclor (Cefaclor)/Clonidine". Individual #2's Medical Emergency Information also states that the individual is allergic to Penicillin.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.The Medication Administration Records for individual #2 was updated, on 9/24/20, to state that the individual is allergic to Penicillin and Clonidine/Cephalosporins (Attachments 3 & 4). The Program Specialist for individual #2 hand-wrote the allergies on the September MAR and added the allergies to the electronic template for individual #2 (October MAR). All Program Specialists participated in a training, on 10/6/20 (Page 8), which included accurate documentation on MARs. 10/06/2020 Implemented
SIN-00151034 Renewal 03/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1 completed fire safety training on 5/24/17 and not again until 6/28/18.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f).The next fire safety training is scheduled for 6/12/19, 16 days earlier than the 2018 date. This issue was discussed with EARS Management Team on 3/20/19 and all members of the Management Team were made aware of the need to have the fire safety training scheduled in a timely manner, in order to prevent this non-compliance from occurring in the future. EARS Client Services Director, Carol Martin, was able to schedule this date with a qualified fire safety expert. EARS will look into purchasing a qualified video, in order to prevent scheduling difficulties in the future. 03/20/2019 Implemented
2380.53(a)Cleaning products that contained the message to contact poison control if ingested were found left unlocked in both the men and women's restroom off of the SSU room; also in an unlocked cabinet in the 123 room; also found in the women's bathroom, sitting on the floor inside a bathroom toilet stall off of the AU room; and again in the Men's bathroom (a jar of Desitin Crème with the same poison control message) off of the 123 room.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The cleaning products in the men and women's restroom off of the SSU room; in the unlocked cabinet in the 123 room; in the men's restroom off of the 123 room (Desitin); and the women's restroom off of the AU room were all removed and immediately locked in a closet on 3/18/19. Locked cabinets were added to the SSU men's and women's restrooms. These cabinets are to be used to store cleaning products that are used in the restroom, as well as, personal hygiene products. The cleaning product in the women's restroom off of the AU room was removed and will not be replaced. All EARS DSP's, program specialists and housekeeping personnel were trained, on 3/22/19, in order to prevent recurrence of this non-compliance. 03/28/2019 Implemented
2380.55(a)Green mats on the floor in the sensory room off of the AU room was visibly dirty.Clean and sanitary conditions shall be maintained in the facility.The green mats were cleaned on 3/19/19. EARS housekeeping department was informed on 3/18/19 that the mats were visibly dirty. EARS housekeeping department has added cleaning of the green mats to the list of items to be cleaned on a daily basis in the AU room. A picture of the clean mats is attached. All program specialists and housekeeping staff were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/22/2019 Implemented
2380.84A fire safety inspection was completed by a fire safety expert on 5/24/17 and not again until 6/28/18.The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept.The next fire safety inspection is scheduled for 6/12/19, 16 days earlier than the 2018 date. This issue was discussed with EARS Management Team on 3/20/19 and all members of the Management Team were made aware of the need to have the fire safety inspection scheduled in a timely manner, in order to prevent this non-compliance from occurring in the future. EARS Client Services Director, Carol Martin, was able to schedule this date with a qualified fire safety expert. 03/20/2019 Implemented
2380.111(c)(4)Individual #5's physical form dated 7/24/18 did not include an evaluation of his vision and hearing.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The physical form for Individual #5 was updated by their PCP, on 3/28/19, to include information related to evaluation of vision and hearing. That section now reads N/A as the PCP was unable to complete assessment of vision and hearing at the annual physical. Individual #5's parents will have vision and hearing assessed, as needed. All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/28/2019 Implemented
2380.111(c)(7)Individual #5's physical form dated 7/24/18 under section titled "assessment of health and maintenance needs" 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.The physical form for Individual #5 was updated by their PCP, on 3/28/19, to include information related to assessment of health and maintenance needs. That section now reads, "foot health hygiene". All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/28/2019 Implemented
2380.111(c)(10)On Individual #5's physical form, dated 7/24/18, the section titled "information pertinent to diagnosis in case of emergency" was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical form for Individual #5 was updated by their PCP, on 3/28/19, to include information pertinent to diagnosis in case of emergency. That section now reads, "intermittent explosive disorder". All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/28/2019 Implemented
2380.113(c)(3)Staff #2's physical dated 11/30/2018 did not include a signed statement that the staff member is free of serious communicable diseases.The physical examination shall include: A signed statement that the person is free of serious communicable diseases 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, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.The most recent EARS staff physical, completed on 2/18/19, is attached. The physician signed the statement that the staff member is free of serious communicable diseases. This issue was discussed with EARS Management Team on 3/20/19 and all members of the Management Team and staff supervisors.were made aware of the need to have all sections of staff physicals filled out, in order to prevent this non-compliance from occurring in the future. 03/20/2019 Implemented
2380.124(a)Individual #5 takes the medication Clonazepam 1mg TAB at 12Noon. The MAR states "Clonazepam 1mg TAB take 1 tab by mouth 2xa day for anxiety" but the medication bottle label states "take 1 TAB 2x's daily and 1/2 TAB as needed for anxiety".A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.The MAR for individual #5 was updated, on 3/20/19, to include the 1/2 TAB, as needed, for anxiety. All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/22/2019 Implemented
2380.173(1)(ii)Individual #2's record did not contain information regarding her race, hair color, eye color, or identifying marks.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.Individual #2's record was updated, on 3/20/19, to include information regarding her race, hair color, eye color, and identifying marks. The record now reflects that individual #2 is caucasian, has blue eyes, and has no identifying marks. All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/22/2019 Implemented
2380.173(1)(iii)Individual #2's record did not contain information regarding her means of communication.Each individual's record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English.Individual #2's record was updated, on 3/20/19, to include information regarding her means of communication. The record now states that Individual #2 speaks English and English is the primary language spoken in her home. All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/22/2019 Implemented
2380.173(1)(iv)Individual #2's record did not contain information regarding her religious affiliation.Each individual's record must include the following information: Personal information including: Religious affiliation.Individual #2's record was updated, on 3/19/19, to include information regarding her religious affiliation, which is unknown. All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/20/2019 Implemented
2380.176(a)Individual record information was found being stored in the 123 room in an unlocked cabinet in the top drawer and also in the top, right side of a desk drawer in the AU room.Individual records shall be kept locked when they are unattended.The individual record information found being stored in the 123 room was moved on 3/18/19 to a locked cabinet in the Program Specialist's office. A picture of the binder in the locked cabinet is attached. The individual record information found in the top, right side of the desk drawer in the AU room was moved on 3/18/19, to a locked cabinet in the Program Specialists office. This information was for several program participants and has been relocated to their individual records in the locked cabinet. All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/22/2019 Implemented
2380.181(e)(6)Individual #5's 6/15/18 annual assessment does not state his ability to use and avoid poisonous materials. it should state that the individual is not poison safe and poisons must be locked up. it only states that the individual should be monitored closely around poisons because there was a situation/incident where he ingested a poisonous material while in school.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.Individual #5's assessment was updated on 3/22/19 to include his ability to use and avoid poisonous materials. Assessment now states that Cody is not poison safe. All program specialists were trained on 3/22/19 in order to prevent this non-compliance from occurring in the future. 03/22/2019 Implemented
SIN-00130925 Renewal 03/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Staff #1 completed 15.5 hours of training in the 2016-2017 training year.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.Staff #1 was on an LOA for several months during the 2016-17 training year. Staff #1 has received 33 hours of training so far in the 2017-18 training year (attachment 36(c)). A new procedure was implemented to have staff complete training requirements upon their return from an LOA. This new procedure will be reviewed with all supervisors at a training on 4/11/18, in order to prevent this non-compliance from occurring in the future. 04/11/2018 Implemented
2380.62The emergency phone numbers were not located near the phone in the SSU 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.Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were attached to the telephone handsets (attachment 62). This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.111(c)(5)Individual #1 had a tuberculin skin test read on 7/10/15 and not again until 8/11/17.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.A section for Tuberculin skin testing and date was added to the EARS physical form checklist (attachment 111 c 5) for the Program Specialist to review when they receive a completed physical form. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.111(c)(8)Individual #2's physical completed on 8/2/17 did not include physical limitations. This section of the physical was left blank.The physical examination shall include: Physical limitations of the individual.The physical for individual #2 (attachment 111 c 8) was updated on 4/4/18, to include that individual #2 does not have any physical limitations. A section for physical limitations was added to the EARS physical form checklist (attachment 111 c 8) for the Program Specialist to review when they receive a completed physical form. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.113(a)Staff #2 had a physical completed on 4/7/14 and not again until 5/25/16.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.Staff #2's physical is due on 5/28/16. Staff #2 scheduled their physical for early May to ensure that it is completed on time. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.113(c)(2)Staff #2 had a tuberculin skin test read on 4/19/14 and not again until 5/28/16.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.Staff #2's physical is due on 5/28/16. Staff #2 scheduled their physical and Tuberculin skin testing for early May to ensure that it is completed on time. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.124aIndividual #3's March 2018 medication administration record (MAR) did not indicate how many units of Novolog Flexpen Syringe injection were administered on 3/6/18 at noon. Staff initialed in the section on the MAR where the units were to be documented.The medication log must identify the prescribing certified registered nurse practitioner (CRNP) when a medication was prescribed by a CRNP as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners).The MAR for Individual #3 was revised to include the blood sugar level (attachment 124a). The MAR for individual #3 was reviewed with the staff, with proper documentation protocols also reviewed. This regulation was reviewed with all med. certified staff on April 4, 2018, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.128(a)Staff #2 had medication administration training on 8/26/16 and not again until 9/1/17.A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.A new form was developed (attachment 128(a)) for easier tracking of medication administration training reviews. This form will now be used for all medication trained staff, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.173(9)Individual #3's assessment completed on 2/19/18 stated that he/she is able to swim. Individual #3's ISP updated 3/8/18 states that he/she is not able to swim.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Individual #3 was a new admission at the end of 2017. The EARS Program Specialist requested a copy of the ISP for this individual and completed the assessment on 2/19/18. The ISP stated that Individual #3 was able to swim. The Program Specialist used that information to complete the assessment and included that individual #3 was able to swim. The updated ISP states that individual #3 is not able to swim. The Program Specialist confirmed with the residential provider that individual #3 is indeed unable to swim. The assessment attachment 173.9) was updated to reflect that individual #3 is unable to swim. This regulation was reviewed with all Program Specialists, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(e)(10)Individual #3's 2/19/18 assessment did not include his/her lifetime medical history. The assessment said to see attached for the lifetime medical history but it was not attached. Individual #4's 8/15/17 assessment did not include his/her lifetime medical history.The assessment must include the following information: A lifetime medical history.The assessments (attachments 181(e)(10)) for individual #3 and #4 were updated to include their lifetime medical history. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(e)(12)Individual #1's assessment completed on 3/14/18 and Individual #2's assessment completed on 3/23/18 both did not include recommendations specific to areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessments (attachment 181 (e)(12)) for individual #1 and individual #2 were updated to include recommendations specific to areas of training, programming and services. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(e)(13)(i)Individual #2's assessment completed on 3/23/18 did not include progress and growth in the area of health.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The assessment for individual #2 was updated to include progress and growth in the area of health. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(e)(13)(ii)Individual #2's assessment completed on 3/23/18 did not include progress and growth in the area of motors skills.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The assessment for individual #2 was updated to include progress and growth in the area of motor skills. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(e)(13)(iv)Individual #2's assessment completed on 3/23/18 and Individual #4's assessment completed on 8/15/17 both did not include progress and growth in the area of socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The assessments (attachments 181 (e)(13)(iv)) for individual #2 and individual #4 were updated to include progress and growth in the area of socialization. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(e)(13)(v)Individual #4's assessment completed on 8/15/17 did not include progress and growth in the area of recreation.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The assessment (attachment 181(e)(13)(v)) for individual #4 was updated to reflect progress and growth in the area of recreation. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(e)(13)(vi)Individual #4's assessment completed on 8/15/17 did not include progress and growth in the area of community integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The assessment (attachment 181(e)(13)(vi) for individual #4 was updated to reflect progress and growth in the area of community integration. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.181(f)Individual #1's assessment completed on 3/14/18 was not sent to his/her individual support plan (ISP) team 30 days prior to the ISP meeting. Individual #2's assessment completed 3/23/18 was not sent to the ISP team 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The Program Specialists are now going to complete the assessment at least 5 months prior to the ISP annual date. The Program Specialists will track this information on their client roster information sheet (attachment 181(f)). This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.186(c)(2)Individual #2's ISP reviews completed on 1/26/18, 10/26/17, 7/20/17 and 4/27/17 did not include a review of his/her social, emotional, environmental needs plan for the entire review period that each ISP review covered.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Individual #2's most recent ISP review (attachment 186 c 2), dated 1/26/18, was amended to include data for the entire review period. The ISP review was missing data from 10/26-10/31. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.186(d)Individual #2's ISP reviews completed on 1/26/18, 10/26/17, 7/20/17 and 4/27/17 were not sent to his/her family. Individual #3's ISP review completed on 3/20/18 was not sent to his/her family. Individual #2 and Individual #3 both have family members who are part of their ISP team.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Individual #2's most recent ISP review (attachment 186 d), completed on 1/26/18, was sent to their family on 4/2/18. After reviewing the ISP review, individual #2's mother will decide if she wants to receive future ISP reviews. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
2380.186(e)Individual #1's record did not include an option to decline ISP review documentation for his/her family members who are part of the ISP team. Individual #2's family was not offered the option to decline ISP review documentation. Individual #3's family members were not offered the option to decline ISP review documentation.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The quarterly template (attachment 186 e) was amended to include an option to decline receiving any further ISP reviews. This form was implemented on 4/4/18. This regulation was reviewed with all Program Specialists on 4/4/18, in order to prevent this non-compliance from occurring in the future. 04/04/2018 Implemented
SIN-00102587 Renewal 11/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1 and Staff #4 received fire safety training on 2/7/15 and not again until 6/1/16. Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).The annual fire safety training will be held annually, on or before 6/1/16, by a fire safety expert. The fire safety company previously hired by EARS to complete the inspection was significantly understaffed in February and unable to complete the fire safety training. The company became fully staffed in May and was able to complete the training on 6/1/16. Getz, inc. has assured us, by phone on 11/14/16, that this will not occur in the future. EARS has used Getz for many years (over 20), with no issues. We are confident that they will be able to provide our training without delay. 11/14/2016 Implemented
2380.84Annual onsite fire safety inspection was completed on 2/10/15 and not again until 6/1/16. 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 annual fire safety inspection will be conducted annually, on or before 6/1/16, by a fire safety expert. The fire safety company previously hired by EARS to complete the inspection was understaffed in February and unable to complete the inspection. The company became fully staffed in May and was able to complete the inspection on June 1st. Getz, Inc. has assured us, by phone on 11/14/16, that this will not occur in the future. EARS has used Getz for many years (over 20), with no issues. We are confident that they will be able to provide our inspection without delay. 11/14/2016 Implemented
2380.173(1)(ii)Individual #1's record did not contain color of eyes. Individual #3's record did not contain height, weight, color of hair, color of eyes, or identifiying marks. 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.The personal information record for Individual #1 was updated to include the color of eyes. The personal information record for Individual #3 was updated to include the height, weight, color of hair, color of eyes, and identifying marks. All Program Specialists were trained on this regulation, on 11/14/16 in order to prevent this non-compliance in the future. 11/14/2016 Implemented
2380.173(1)(iv)Individual #3's record did not contain religious affiliation. Each individual¿s record must include the following information: Personal information including: Religious affiliation.The record for Individual #3 was updated to contain religious affiliation. All Program Specialists were trained on this regulation, on 11/14/16 in order to prevent this non-compliance in the future. 11/14/2016 Implemented
SIN-00086336 Renewal 11/03/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)There was hand sanitizer sitting next to the first aid cot and not locked away. All individuals reviewed needed poisons locked. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The hand sanitizer was placed in a locked cabinet, in the same room, on 11/5/15. A photo of the locked cabinet is attached. All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future. 11/05/2015 Implemented
2380.89(c)The fire drill record for the fire drill was held on 6/3/2015 did not include the time the fire drill was conducted or the evacuation time. A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.The Program Specialist responsible for keeping record of the fire drill written record obtained the information from the adjoining program to complete the form. All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future. 11/16/2015 Implemented
2380.111(c)(6)Individual #2's physical did not inlcude a spot for the physican to check communicable disease status. 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.The copy of the physical in Individual #2's file had the spot for the physician to check communicable disease status was a bad copy which had this section cut off. The Program Specialist contacted the residential provider and received a better copy of the original physical clearly stating no communicable diseases. All Program Specialists were trained on 11/13/15 in this regulation to prevent this non-compliance from occurring in the future. 11/16/2015 Implemented
2380.128(a)Staff #1 completed her last medication training with an annual date of 3/22/13. Staff #1 completed 4 observations by 12/10/14 but did not finish by 3/22/14. A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.Staff #1 was trained on medication administration and passed her test on 11/11/15. Observations were completed 11/18/15. Staff #1 is now certified to pass medications.(All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future.)JR 12/8/15 11/18/2015 Implemented
2380.128(d)Staff #1 had been passing medications and was not certified. A staff person who administers prescription medications or insulin injections to individuals shall complete the Medications Administration Course Practicum annually.Staff #1 stopped passing medications on 11/4/15 and did not pass medications again until she was recertified on 11/18/15.(All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future.)JR 12/8/15 11/18/2015 Implemented
2380.173(1)(ii)Individual #1 and individual #2's record did not have identifying marks which was blank. 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.The Personal Record Information for Individual #1 & #2 was updated to reflect identifying information for these Individuals. All Program Specialists were trained on 11/13/15 in this regulation to prevent this non-compliance from occurring in the future. 11/16/2015 Implemented
2380.173(1)(iv)Individual #1 and #2's record did not include religion which was blank. Each individual¿s record must include the following information: Personal information including: Religious affiliation.The Personal Record Information form for Individual #1 and Individual #2 was updated to reflect their religious affiliation. The religious affiliation for both individuals is unknown. All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future. 11/16/2015 Implemented
2380.173(9)Individual #3's physical stated low fat, low cholesterol, limit sugar intake, cut up meats into small pieces, and slow down when eat and drinks. The assessment states a low sugar diet. The assessment states unsupervised for 10 minutes in the program and 5 minutes at lunch. Then the assessment stated unsupervied for 10 minutes at lunch, leisure, and bathroom. Individual #1's physical states allergic to spray cleaners. MAR's stated allergic to spray cleaners along with raw tomatoesm citrus, and melons.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The assessment for Individual #3 was amended on 12/2/15 to reflect that he is on a low fat, low cholesterol, limited sugar intake, cut up meats into small pieces and slow down when eats and drinks. The assessment now matches the ISP. The assessment for Individual #3 was amended to state the level of supervision 1 time in the assessment as opposed to 2 times. The assessment matches the level of supervision listed in the ISP. The MAR for Individual #1 was amended to reflect that he is only allergic to spray cleaners. The physical, MAR and ISP all match. All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(5)Individual #2's assessment did not include the ability to self-administer. The assessment must include the following information: The individual¿s ability to self-administer medications.The assessment template was revised to address medication administration. The assessment for Individual #2 was revised on 12/2/15 to reflect her ability to self-administer medications. All Program Specialists were trained on this regulation on 11/13/15 to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(6)Individual #1's assessment did not include ability to safely use or avoid poisons. 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.The assessment template was revised to include an individuals ability to safely use or avoid poisons. Individual #1's assessment was revised on 12/2/15 to reflect his ability to safely use or avoid poisons. All Program Specialists were trained in this regulation on 11/13/15 to prevent this non-compliance from occurring in the future. 11/13/2015 Implemented
2380.181(e)(7)Individual #1, #2, #3's assessment did not inlcude whether to move away from heat sources. 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.The assessment template was revised to include an individual's ability to move away from heat sources. The assessments for individual #1, #2 and #3 were revised to include their ability to move away from heat sources. All Program Specialists were trained on this regulation on 11/13/15 to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(12)Individual #1's assessment did not include recommendations pertaining to 2380 services. The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment template was revised to include training and placement recommendations. The assessment for Individual #1 was amended to include training and placement recommendations for this individual. All Program Specialists were trained on this regulation on 11/13/15 to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(13)(i)Individual #3's assessment did not include progress and over the last 365 calendar days and current level in health. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The assessment for Individual #3 was amended on 12/2/15 to include their progress and growth over the last 365 calendar days and current level in health. All Program Specialists were trained on this regulation on 11/13/15 to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(13)(ii)Individual #3's assessment did not include progress and over the last 365 calendar days and current level in motor and communication skills. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The assessment for Individual #3 was amended on 12/2/15 to include their progress and growth and current skill level in motor and communication skills. All Program Specialists were trained on 11/13/15 in this regulation to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(13)(iii)Individual #3's assessment did not include progress and over the last 365 calendar days and current level in personal adjustment. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The assessment for Individual #3 was amended on 12/2/15 to include their current skill level and progress and growth over the last 365 calendar days in personal adjustment. All Program Specialists were trained on this regulation on 11/13/15 to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(13)(iv)Individual #3's assessment did not include progress and over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The assessment for Individual #3 was amended on 12/2/15 to include their current skill level and progress and growth in socialization. All Program Specialists were trained on 11/13/15 in this regulation to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(13)(v)Individual #3's assessment did not include progress and over the last 365 calendar days and current level in recreation. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The assessment for Individual #3 was amended on 12/2/15 to include their current skill level and progress and growth over the last 365 calendar days in recreation. All Program Specialists were trained on 11/13/15 in this regulation to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(13)(vi)Individual #3's assessment did not include progress and over the last 365 calendar days and current level in community-integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The assessment for Individual #3 was amended to include their progress and growth over the last 365 calendar days and current level in community-integration. All Program Specialists were trained on 11/13/15 in this regulation to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.181(e)(14)Individual #1 and #2's assessment did not include water safety. The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.The assessments for individual's #1 or #2 were amended on 12/2/15 to include their water safety. All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future. 12/02/2015 Implemented
2380.183(5)Individual #3's ISP did not include a SEEN plan. It states that he gets upset and when he gets upset, staff are to use the behavioral plan. However EARS has their own plan they use at day program. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.On 11/30/15 the Program Specialist sent an email to the SC requesting a change to the Social/emotional section of individual #3's ISP. The change reflects the fact that Individual #3 has a SEEN plan at EARS and documentation is kept on site. All Program Specialists were trained in this regulation on 11/13/15 to prevent this non-compliance from occurring in the future. 11/13/2015 Implemented
2380.186(c)(1)Individual #2's ISP reviews did not review on 8/3/15 the outcome goal of sitting at her seat within 10 minutes of getting to program. The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Individual #2 moved from a 2390 to a 2380 program. This move occurred on 6/1/15, with the official assessment period deadline of 8/1/15. 6/1/15 began the assessment period for this individual. On 7/31/15 a Critical Revision meeting was held, with the outcome being implemented on 8/3/15, the next work day as it was determined that the outcome was still appropriate. On 8/3/15 a quarterly meeting was held and the outcome was reviewed as program staff had continued to document the outcome, during the assessment period, to determine if it was still appropriate. (All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future.)JR 12/8/15 11/13/2015 Implemented
2380.186(d)Individual #3's ISP reveiws for 11/25/14 and 5/25/15 weren't sent to his sister or POA.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.The ISP reviews for 11/25/14 and 5/25/15 were sent to his sister and POA on 11/13/15. A new ISP review was held 11/25/15 and was sent to his sister and POA. (All Program Specialists were trained on 11/13/15 on this regulation to prevent this non-compliance from occurring in the future.)JR 12/8/15 11/13/2015 Implemented
2380.186(e)Individual #3 record did not include the option to decline the ISP review documentation for his sister and POA. The SC who started on 6/4/14 did not receive option to decline until 2/24/15. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.A revision was made to the ISP review template form to include a statement notifying plan team members of the option to decline the ISP review documentation. All Program Specialists were trained on this regulation on 11/13/15 in order to prevent this non-compliance from occurring in the future. 11/13/2015 Implemented
SIN-00193760 Renewal 09/28/2021 Compliant - Finalized
SIN-00077278 Initial review 04/16/2015 Compliant - Finalized