Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280011 Renewal 12/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(3)(ii)Individual #1's annual assessment dated 11/8/25 did not include the individual's progress over the last 365 calendar days in the following area: Communication.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication.Program Specialist is making corrections to the annual assessment to reflect progress as well as current level for communication. 01/13/2026 Implemented
2380.181(e)(13)(i)Individual #1's annual assessment dated 11/8/25 did not include the individual's progress over the last 365 calendar days in the following area: healthThe assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Program Specialist is making corrections to the annual assessment to reflect progress as well as current level for level of health. 01/13/2026 Implemented
2380.181(e)(13)(iii)Individual #1's annual assessment dated 11/8/25 did not include the individual's progress over the last 365 calendar days in the following area: Personal AdjustmentThe 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.Program Specialist made corrections to the annual assessment to reflect progress as well as current level for personal adjustment. 01/13/2026 Implemented
2380.181(e)(13)(iv)Individual #1's annual assessment dated 11/8/25 did not include the individual's progress over the last 365 calendar days in the following area: 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.Program Specialist made corrections to the annual assessment to reflect progress as well as current level for socialization. 01/13/2026 Implemented
2380.181(e)(13)(v)Individual #1's annual assessment dated 11/8/25 did not include the individual's progress over the last 365 calendar days in the following area: RecreationThe assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Program Specialist made corrections to the annual assessment to reflect progress as well as current level for recreation. 01/13/2026 Implemented
2380.181(e)(13)(vi)Individual #1's annual assessment dated 11/8/25 did not include the individual's progress over the last 365 calendar days in the following area: Community IntegrationThe 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.Program Specialist Made corrections to the annual assessment to reflect progress as well as current level for community integration. 01/13/2026 Implemented
2380.125(b)Prescription orders are not kept current. Individual #1 is prescribed Nayzilam as needed for seizures. This medication expired on 12/11/25.A prescription order shall be kept current.Effective immediately, expired medication was sent home, and new medication was requested from the family. New medication received 1/5/2026 upon his return from holidays. 01/05/2026 Implemented
SIN-00241456 Renewal 03/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill records for fire drills conducted on 1/30/2024 and 2/26/2024 did not document the exit routes used.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 fire drill record was amended on 3/18/24 to include the exit route. All staff that maintain this record were instructed to use this document and to ensure exit routes are always marked. 03/18/2024 Implemented
2380.176(a)Individual records were found in an unlocked cabinet located over the television in the main program area.Individual records shall be kept locked when they are unattended.The individual records were removed from the cabinet in question on 3/18/24 and put in a cabinet in a closet that is kept locked. CPS staff were reminded that any confidential information must be kept in locked cabinets or rooms. 03/18/2024 Implemented
SIN-00219644 Renewal 03/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)An unannounced fire drill shall be held at least once a month. There is no record or documentation that a May 2022 fire drill occurred.An unannounced fire drill shall be held at least once a month.The ATF will ensure a monthly fire drill occurs by designating a primary and a secondary staff to be responsible for the completion. The designated staff will maintain a yearly calendar with dates identified in advance that will be shared with the director. If for any unforeseen circumstances, by the 25th day of the month the fire drill has not been completed, the secondary staff will contact the primary staff and/or complete the fire drill. 03/20/2023 Implemented
2380.89(c)A written fire drill record shall be kept of the exit route used. The fire drill conducted on 10/24/22, 9/22/22, 8/31/22, 7/29/22, 4/25/22 did not document the exit route used as this section of the forms was left blank.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 will complete the fire drill record in its entirety. The PS will then provide the record to a designated staff that will review the document for missing information, communicate any concerns and then sign/date verifying it is completed. 03/20/2023 Implemented
2380.111(a)Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had a physical examination on 5/3/21 and their next physical examination occurred on 6/9/2022. This exceeds the requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialist will maintain a spreadsheet detailing the previous date of physical examination for every individual. Two months prior to the expiration, a reminder letter will be sent home by the PS. One month prior to expiration, a second reminder letter will be sent home by the PS. If two weeks prior to expiration, the individual has not had the physical completed or communicated the date it is scheduled for, the PS will speak with the individual/caregiver to explain this exceeds the regulatory requirement. 03/20/2023 Implemented
SIN-00200551 Renewal 03/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisonous materials were not [locked or in accessible to the individuals. There were 6 bottles of hand sanitizer located in an unlocked cabinet and one on the counter of the program room. All of the bottles stated to contact poison control.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Program Specialist will review each individual's assessment and ISP to make sure they document the individuals ability to safely use or avoid poisonous materials. 03/04/2022 Implemented
2380.181(e)(14)Individual #1's annual assessment dated 8/28/21 did not address the individual's ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.Program Specialist will review individual assessments and ISP's to make sure all aspects of water safety are acknowledged. 03/17/2022 Implemented
SIN-00170248 Renewal 02/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(12)There were no recommendations in the required areas in Individual #1's assessment dated 10/22/2019.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Program Director and Program Specialist will conduct a review of all assessments to ensure "Recommendation" section is included containing the following information - recommendation for specific areas of training, vocational programming and competitive community integrated employment. This section will be added to any assessment missing this information. 02/10/2020 Implemented
2380.181(f)Individual #2's assessment was not sent to her team 30 days prior to her ISP meeting. Her ISP meeting was held on 6/17/2019 and her assessment was not completed until 5/22/2019.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Program Director and Program Specialist will conduct a review of all assessment due dates on a monthly basis to ensure the assessment is provided to all individual plan team members at least 30 days prior to individual plan meeting. Program Specialist will provide assessments to individual team members 30 calendar days prior to scheduled individual team meeting. 02/10/2020 Implemented
SIN-00150473 Renewal 02/14/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(g)The fire drill logs didn't mention if the individuals were able to evacuate to the designated meeting place(s).Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Additional verification block has been added to fire drill log to confirm all individuals evacuated to the designated meeting place outside the facility. 02/15/2019 Implemented
2380.111(a)Individual #2 started the program on 05-24-18 and the physical in her file is from 2012.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.All individuals will have a physical within 12 months prior to admission to the program and annually thereafter. Program Specialist will review all individual files to confirm compliance. 02/15/2019 Implemented
SIN-00129209 Renewal 02/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)The Health Maintenance Needs section wasn't completed on Individual #1's physical exam dated 1/19/2018 and Individual #2's physical exam dated 9/13/2017.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.55 Pa Code Chapter 2380.111(c)(7) All physicals shall include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Program Specialist will review all physicals received for compliance. ((This information will be requested for Individual #1 and Individual #2 -CH 5/8/2018)) 03/05/2018 Implemented
2380.111(c)(10)This section wasn't completed on Individual #1's physical exam dated 1/19/2018.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.55 Pa Code Chapter 2380.111(c)(10) All physicals shall include medical information pertinent to diagnoses and treatment in case of emergency. Program Specialist shall review all physicals received to insure required information is completed. ((this information will be requested for Individual #1 - CH 5/8/18)) 03/05/2018 Implemented
SIN-00108241 Renewal 03/29/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #2's TB test was late. It was completed on 01/20/15, then not again until 03/23/17.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.55 PA Code Chapter 2380.111(c)(5) Consumer TB testing will be completed every 2 years as required. Program Specialist will monitor testing dates to insure compliance with skin testing or chest x-ray as applicable. 05/01/2017 Implemented
2380.111(c)(7)The section pertaining to the assessment of the individual's health maintenence needs was left blank on Individual #2's physical form.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.55 PA code Chapter 2380.111(c)(7) Physical form for individual #2 has been revised to include health maintenance needs. Program Specialist and Program Director will monitor forms to insure all areas are completed. 05/01/2017 Implemented
2380.111(c)(10)The section regarding information pertinent to diagnosis and treatment in case of an emergency was left blank on Individual #2's physical form and and there was not even a section addressing it on Individual #1's physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.55 PA Code Chapter 2380,111(c)(10) Physical form for individuals #1 & 2 have been revised to include information relating to diagnosis and treatment in case of emergency. Program Specialist and Program Director will monitor form to insure all areas are completed. 05/01/2017 Implemented
2380.173(1)(ii)The section pertaining to identifying marks on Individual #1's and Individual #3's files was left blank. The sections pertaining to weight and height were also blank for Individual #1.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.55 PA Code Chapter 2380.173(1)(ii) Records of individuals #1 & 3 have been revised to include weight, height, identifying marks, as applicable,. Personal information records will be monitored by Program Specialist to insure all areas of form are completed. 05/01/2017 Implemented
2380.173(1)(iv)The section pertaining to Religious Affiliation in Individual #1's file was left blank.Each individual¿s record must include the following information: Personal information including: Religious affiliation.55 PA Code Chapter 2380.173(1)(iv) Individual #1 personal information has been revised to indicate religious affiliation. Program Specialist and Program Director will monitor forms to insure all areas are completed. 04/07/2017 Implemented
2380.173(1)(v)None of the photos were dated in the files of Individual #1, Individual #2, Individual #3, and Individual #4Each individual¿s record must include the following information: Personal information including: A current, dated photograph.55 PA Code Chapter 2380.173(1)(v) Photos in files of individuals # 1, 2, 3, 4 have been updated/dated by Program Specialist. Staff were reminded that all consumer photos must be dated as to when taken prior to placing in individuals file. Program Specialist and Program Director will monitor all filed to insure compliance. 03/29/2017 Implemented
2380.181(e)(10)The assessments for Individual #1, Individual #2, Individual #3 and Individual #4 did not contain a lifetime medical history.The assessment must include the following information: A lifetime medical history.55 PA Code Chapter 2380.181(e)(10) -Assessments for individuals #1, 2, 3, 4 will be revised by Program Specialist to include lifetime medical history. Program Director will monitor all consumer assessments to insure lifetime medical history is included. 05/01/2017 Implemented
2380.181(f)Individual 2's, Individual 3's, and Individual 4's assessments were not provided to team members at least 30 days before 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).55 PA Code Chapter 2380.181(f) Assessments for individuals #2, 3, 4 will be provided to SC or plan lead, as applicable, and team members at least 30 calendar days prior to scheduled ISP meeting. Letters transmitting this information to required individuals will be placed in consumer(s) file. Program Directors will monitor to insure compliance. 04/07/2017 Implemented
SIN-00090133 Renewal 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #1 was hired on 06/25/2014 and did not have a criminal history record check done until 07/10/2014 which exceeds the 5 day requirement.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.All newly hired staff ( full and part time) who will have direct contact with individuals will have a Pa criminal history record check processed within 5 working days following the person's date of hire. 03/02/2016 Implemented
SIN-00259858 Renewal 03/24/2025 Compliant - Finalized
SIN-00073889 Renewal 01/30/2015 Compliant - Finalized
SIN-00060781 Renewal 03/18/2014 Compliant - Finalized
SIN-00045290 Initial review 02/01/2013 Compliant - Finalized