Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245840 Renewal 06/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #6's physical examination dated 2/1/24 did not include a vision screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Section regarding vision and hearing has been updated for individual 6. 06/17/2024 Implemented
2380.111(c)(5)Individual #3 did not complete a tuberculin skin test with negative results every two years. Individual #1 completed a tuberculin skin test on 5/19/21 and did not complete another until 6/15/23.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.Section regarding tuberculin skin testing with a negative result has been updated for individual 3. 06/17/2024 Implemented
2380.113(c)(3)Staff #1's physical examination dated 2/1/24; Staff #2's physical examination dated 9/15/22 and Staff #3's physical examination dated 1/31/24 did not include a signed statement that the person 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.Staff 1,2, and 3's physicals examinations have been updated free from communicable diseases. 06/17/2024 Implemented
2380.181(e)(12)Individual #1, Individual #2, Individual #3, Individual #4, Individual #5 and Individual #6's annual assessments did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.181(e)(13)(i)Individual #1, Individual #2, Individual #3, Individual #4, Individual #5 and Individual #6's annual assessments did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.181(e)(13)(ii)Individual #1, Individual #2, Individual #3, Individual #4, Individual #5 and Individual #6's annual assessments did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.181(e)(13)(iii)Individual #1, Individual #2, Individual #3, Individual #4, Individual #5 and Individual #6's annual assessments did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.181(e)(13)(iv)Individual #1, Individual #2, Individual #3, Individual #4, Individual #5 and Individual #6's annual assessments did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.181(e)(13)(v)Individual #1, Individual #2, Individual #3, Individual #4, Individual #5 and Individual #6's annual assessments did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.181(e)(13)(vi)Individual #1, Individual #2, Individual #3, Individual #4, Individual #5 and Individual #6's annual assessments did not include the individual's progress over the last 365 calendar days and current level in the following areas: 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.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.181(e)(14)Individual #1 and Individual #2's annual assessments did not include the individual's knowledge of water safety or the ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Individuals 1, 2, 3, 4, 5 and 6's assessments were updated with the corrections by the assigned Program Specialist 06/17/2024 Implemented
2380.38(a)(1)Staff #3 did not complete orientation training within 30 days of hire. Staff #3 was hired on 2/15/24 and did not complete orientation training including: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, 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, Individual rights, recognizing and reporting incidents and job-related knowledge and skills until 4/5/24.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.New staff orientation training packet has been updated to include a date line after signature. * attachment below 06/17/2024 Implemented
SIN-00225643 Renewal 06/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)A small filing cabinet located in the senior room was unlocked and contained Great Value brand cleaning spray which was labeled with the statement "contact poison control" if ingested, several cans of disinfectant spray and a bottle of alcohol-based hand sanitizer in one of the drawers.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.As per regulation 2380.53 a Poisonous materials shall be kept locked or made inaccessible to individuals when in use. Group room staff are required to mark daily log stating if poisonous material remained. 06/30/2023 Implemented
2380.53(b)An unlabeled spray bottle containing an unknown cleaning solution was found in the "1:1 Intensive Supports" room.Poisonous materials shall be stored in their original, labeled containers.As per regulation 2380.53 b, poisonous materials shall be stored in their original labeled container. 06/30/2023 Implemented
2380.111(a)Individual #3 had a late annual physical examination. Individual #1 had a physical examination on 9/07/2021, then not again until 10/04/2021.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.As per regulation 2380.11 a, each individual shall have a physical examination within 12 months prior to admission and annually thereafter. If an individual exceeds grace period after last physical, services will be temporarily suspended until the individual completes the required physical. Proof of completion is required on or before date of return. 07/25/2023 Implemented
2380.181(e)(12)The Individual Assessments for Individual #1 (annual assessment completed on 2/20/2023), Individual #5 (initial assessment completed on 2/20/2023) and Individual #6 (initial assessment completed on 4/10/2023) did not include documentation of recommendations for specific areas of training, vocational programming and competitive community-integrated employment. Each of the assessments listed previously had an area for recommendations but the area was blank.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.As per regulation 2380.181 (e) (12), recommendations for specific areas of training, vocational programming and competitive integrated employment will be completed on all assessment. Individuals #1,5,6 assessments have been updated, see supporting documentation. 07/25/2023 Implemented
2380.21(u)Individual rights were reviewed at admission, and annually thereafter, with Individuals #1, #2, #3, #4, #5 and #6 but the individual rights that were reviewed and the individual rights statements that were signed by individuals or their representatives had not been updated to reflect the current and updated individual rights.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Individuals rights were updated to reflect changes as per regulation 2380.21 (u). Program Specialist will reach out to individuals and persons designated by the individual to review updated individual rights. See attached updated rights. 07/25/2023 Implemented
SIN-00205940 Renewal 06/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill for the Month of April 2022 did not have an evacuation time documented on the fire drill form.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.As per regulation 2380.89c, all sections of fire drills are to filled out at the time of the drill. The Program Manager is responsible for completing this task. In the absence of the Program Manager, the Site Supervisor shall be responsible of completion. 07/06/2022 Implemented
2380.89(g)The fire drill for the month of December 2021 did not have a designated meeting place documented on the fire drill form.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.As per regulation 2380.89g, all sections of fire drills are to filled out at the time of the drill. The Program Manager is responsible for completing this task. In the absence of the Program Manager, the Site Supervisor shall be responsible of completion 07/06/2022 Implemented
SIN-00147548 Renewal 01/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)The Health Maintenance Needs section was blank on Individual #2's physical exam dated 9/12/2018.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 health and maintenance section of Individual #2's physical has been updated. Agency LPN will send a memo to all providers and families recommending they complete as much of the non-medical sections of the physical form as possible prior to the appointment. Upon receipt of program participants annual physicals, both the agency LPN and the individual's Program Specialist will review the record to ensure all sections are completed to satisfy this plan of correction. 02/22/2019 Implemented
2380.181(e)(13)(ii)Progress & growth was not noted in the area of Communication on Individual #1's assessment dated 9/3/2018.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.Individual #1's assessment has been updated in the communication section. Within 60 day after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. 02/22/2019 Implemented
2380.181(e)(13)(iii)Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018The 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.Individual #1's assessment has been updated in the personal adjustment section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. 02/22/2019 Implemented
2380.181(e)(13)(iv)Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018.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.Individual #1's assessment has been updated in the socialization section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. 02/22/2019 Implemented
2380.181(e)(13)(v)Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Individual #1's assessment has been updated in the recreation section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. 02/22/2019 Implemented
2380.181(e)(13)(vi)Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018The 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.Individual #1's assessment has been updated in the community-integration section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. 02/22/2019 Implemented
2380.186(b)Individual #3 did not sign her ISP Reviews dated 7/10/2018 and 10/10/2018.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individual #1 has since signed her ISP. Upon review of the quarterly review with the program participants, Program Specialists will ensure that the individuals are aware of their progress made on goals specified in their ISP by way of their signature. Random audits of program participants file shall be completed by the Program Manager to ensure compliance to this plan of correction. 02/22/2019 Implemented
SIN-00127893 Renewal 02/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a late physical. He had one 10-14-16, then not again until 11-07-17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Physical examinations shall be done within 12 months prior to admission and annually thereafter. The Adult Day Service LPN will send notices home at the 3 month, 2 month, and 1 month interval prior to the expiration of all program participant physical examinations. In the event the program participant does not have a current physical on record the day of expiration, a final notice will be sent home suspending services if a current physical is not on file within 14 business days. Adult Day Service Program Specialists will also be responsible for ensuring program participant files are in compliance with regulatory requirements. 04/18/2018 Implemented
SIN-00108248 Renewal 03/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(8)The section pertaining to physical limitations was left blank on Individual #1's physical form.The physical examination shall include: Physical limitations of the individual.Missing information on physical form for individual #1 was completed. Staff LPN made correction. Individual physical forms will be completed in entirety. 03/13/2017 Implemented
2380.111(c)(10)The section regarding info pertinent to diagnosis and treatment in case of energency was left blank in on the physicals of Individuals 1, 2, and 4.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Section regarding pertinent to diagnosis and treatment in case of emergency has been completed on physicals for individuals 1, 2, and 4. Individual physical will be completed in their entirety. 03/27/2017 Implemented
2380.173(1)(ii)The section in Indivdual #2's and Individual #3's files regarding identifying marks was left 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.Intake sheets updated to include identifying marks, if any, on individual #2 and #3. Assigned Program Specialist make the corrections. At the time of intake and annually thereafter, intake forms will be reviewed and updated. 03/27/2017 Implemented
2380.181(e)(10)The lifetime medical history attached to the assessment of Indivdual #1 was not updated since 1999 and has not been signed as being reviewed since 2015.The assessment must include the following information: A lifetime medical history.Lifetime medical history for individual #1 has been reviewed and signed. Corrections completed by Program Specialist. All lifetime medical s shall be reviewed , updated and signed on an annual basis. Completed 3/27/2017 03/27/2017 Implemented
SIN-00088210 Renewal 02/10/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)A toilet seat in the handicapped stall of the women's bathroom is hazardous. The toilet seat was loose and sitting crooked on the toilet bowl. It appeared to have one screw missing. Floors, walls, ceilings and other surfaces shall be free of hazards.All toilets seats shall be in good condition and free from hazards throughout the program. Toilet seat repaired by maintenance department on 2/11/16. Staff are reminded of importance to report any hazardous conditions throughout the program. This responsibility is also included in new staff orientation. 02/11/2016 Implemented
2380.173(9)The ISP for individual #1 states that the individual "safe around heat sources" and that she "can use cleaning supplies with staff supervision. She would not ingest cleaning supplies, personal hygiene items, or any other non-food items." The Assessment dated 3/25/2015 states that individual #1 is not safe with heat sources or poisons. Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Individual Number 1 assessment has been updated to reflect and be consistent with ISP. Includes that she can be safely around poisons with staff supervision. Completed February 12, 2016. Assigned Program Specialists are responsible on a yearly or ongoing basis to assess service participants areas of need, including safety skills. Assessment and ISP's will be reviewed at the time of completion to insure information in both the assessment and ISP are correct and accurate. 03/11/2016 Implemented
2380.184(a)(1)(i)There is no indication that individual #1 attended her ISP meeting held on 6/3/2015. The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision). A plan team must include as its members the following: The individual.Individual #1 has signed her ISP and made aware of what is contained in the ISP. Program Specialist made this update on February 11, 2016. All Program Specialists will ensure that program participants sign their ISP attendance sheet prior to the start of the meeting. 02/11/2016 Implemented
SIN-00069103 Renewal 11/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The rear door in the pre-voc room is difficult to open. The baseboard molding in the womens bathroom near the cafeteria is broken and missing. One outlet plate in the cafeteria is broken.Floors, walls, ceilings and other surfaces shall be in good repair.Repairs have been made to the molding in the women's bathroom in the cafeteria. The outlet plate has been replaced, and the door in pre-voc is now opening freely. These repairs were completed by the Properties Manager. All program areas shall remain in good repair at all times. When an area is in need of repair,a repair order will be completed and forward to the Properties Manager. The Manager of Adult Day Services is responsible for monitoring the repair needs of the program area. 11/07/2014 Implemented
2380.91(a)Individual #1 was admitted on 09/15/2014 and did not receive the fire safety training until 09/16/2014.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Upon admission, all program participants shall have general fire safety in their primary language or mode of communication. The fire safety will now be part of the intake process, in which all intake packets will have the fire safety form along with all other necessary forms required for admission. The form shall also be listed on the intake checklist in order to ensure it is not overlooked. The assigned program specialist will be responsible for this correction and ongoing monitoring of it's completion. 11/07/2014 Implemented
SIN-00169134 Renewal 01/24/2020 Compliant - Finalized
SIN-00053676 Renewal 10/09/2013 Compliant - Finalized