Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220928 Renewal 04/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(7)Individual #1's Individual Assessment, dated 03/10/2023, does not contain information regarding the individual's knowledge of the danger of heat sources or his ability to move away from heat sources quickly. In the corresponding section of the assessment, it states only that the individual "needs assistance with setting his bath water temperature" and does not mention the individual's level of awareness of the danger of this or any other heat source. In addition, the assessment does not describe whether the individual would be able to move away quickly from this or any other heat source with which the individual unintentionally came into contact. The assessment should specify the individual's level of knowledge and skill in this area in the absence of protections or assistance in addition to the protection or assistance the individual requires to remain safe in practice. Individual #2's Individual Assessment, dated 03/09/2023, does not contain information regarding the individual's knowledge of the danger of heat sources or his ability to move away from heat sources quickly. In the corresponding section of the assessment, it only outlines the assistance the individual requires to safely adjust his water temperature--it does not mention the individual's level of awareness of the danger of this or any other heat source. In addition, the assessment does not describe whether the individual would be able to move away quickly from this or any other heat source with which the individual unintentionally came into contact. The assessment should specify the individual's level of knowledge and skill in this area in the absence of protections or assistance in addition to the protection or assistance the individual requires to remain safe in practice. Individual #3's Individual Assessment, dated 01/19/2023, does not contain information regarding the individual's knowledge of the danger of heat sources or his ability to move away from heat sources quickly. In the corresponding section of the assessment, it only states that the individual is encouraged to use the stove top and oven when others are home --it does not mention the individual's level of awareness of the danger of this or any other heat source. In addition, the assessment does not describe whether the individual would be able to move away quickly from this or any other heat source with which the individual unintentionally came into contact. The assessment should specify the individual's level of knowledge and skill in this area in the absence of protections or assistance in addition to the protection or assistance the individual requires to remain safe in practice.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.ALL Program Specialist received a training on April 19, 2023, on the annual assessments, to determine how to evaluate the VIP's knowledge of heat sources. The DSP's are reviewing all assessments and making sure that knowledge of skill is amended into the assessment. 04/19/2023 Implemented
SIN-00203958 Renewal 04/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual #2's annual physical dated 6/3/2021 did not include previous medical history.The physical examination shall include: A review of previous medical history.Physical forms were submitted to the families to give to PCP to have medical history completed 05/27/2022 Implemented
2380.111(c)(4)Individual #2's annual physical dated 6/3/2021 did not include a vision or hearing examination.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The physical was returned to the family to have the vision and hearing section completed by the PCP. 05/27/2022 Implemented
2380.111(c)(7)Individual #1's physical exam dated 1/26/22 the health maintenance needs section was left blank on the 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.The physical was sent to the family to have it returned to the PCP to have health maintenance section completed. 05/27/2022 Implemented
2380.111(c)(10)Individual #2's annual physical dated 6/3/2021 did not include information in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical was returned to the family to have the PCP complete the pertinent to diagnosis section completed properly. 05/26/2022 Implemented
2380.111(c)(11)Individual #2's annual physical dated 6/3/2021 did not include special diet instructions.The physical examination shall include: Special instructions for an individual's diet.The physical was returned to the family to have the PCP complete the special instructions for and individual's diet. 05/27/2022 Implemented
2380.113(a)Staff #1 had a physical exam on 10/15/19 and did not have another physical exam completed until 2/11/22. This exceeds the requirement.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.The staff did the complete the physical and it was 4 months late due to an error between two staff. 05/26/2022 Implemented
2380.113(c)(2)Staff #1 had a Tuberculin skin testing with negative results on 10/17/19 and their next Tuberculin skin testing with negative results was completed on 2/13/22. This exceeds the requirement.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.The staff did the complete the TB skin test 4 months late due to an error between two staff. 05/26/2022 Implemented
SIN-00163411 Renewal 10/01/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)This section was blank on Individual #3's physical exam dated 3/20/2019.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The physical form was not a Cares physical form. It was provided to us when the VIP started program. Cares will ensure that only Cares physical forms are accepted. ((CARES will review all individual physical examinations to ensure compliance. If any required information is found missing on a physical examination, CARES will contact the individual's physician to obtain the required information. The review will be completed by 12/1/19 -CH 10/22/19)) 10/03/2019 Implemented
2380.111(c)(7)The Health Maintenance Needs section was blank on Individual #3's physical exam dated 3/20/2019 (Repeat Violation: 10/5/2018).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 physical form was not a Cares physical form. It was provided to us when the VIP started program. Cares will ensure that only Cares physical forms are accepted to prevent further incidents. ((CARES will review all individual physical examinations to ensure compliance. If any required information is found missing on a physical examination, CARES will contact the individual's physician to obtain the required information. The review will be completed by 12/1/19 -CH 10/22/19)) 10/03/2019 Implemented
2380.111(c)(8)This section was blank on Individual #1's physical exam dated 12/13/2018 and Individual #3's physical exam dated 3/20/2019 (Repeat Violation: 10/5/2018).The physical examination shall include: Physical limitations of the individual.The physical form was not a Cares physical form. It was provided to us when the VIP started program. Cares will ensure that only Cares physical forms are accepted to prevent further incidents. ((CARES will review all individual physical examinations to ensure compliance. If any required information is found missing on a physical examination, CARES will contact the individual's physician to obtain the required information. The review will be completed by 12/1/19 -CH 10/22/19)) 10/03/2019 Implemented
2380.111(c)(9)This section was blank on Individual #3's physical exam dated 3/20/2019 (Repeat Violation: 10/5/2018).The physical examination shall include: Allergies or contraindicated medication.The physical form was not a Cares physical form. It was provided to us when the VIP started program. Cares will ensure that only Cares physical forms are accepted. ((CARES will review all individual physical examinations to ensure compliance. If any required information is found missing on a physical examination, CARES will contact the individual's physician to obtain the required information. The review will be completed by 12/1/19 -CH 10/22/19)) 10/03/2019 Implemented
2380.111(c)(11)This section was blank on Individual #1's physical exam dated 12/13/2018 and Individual #3's physical exam dated 3/20/2019 (Repeat Violation: 10/5/2018).The physical examination shall include: Special instructions for an individual's diet.The individual does not have any current dietary restrictions. That is ehy the PS overlooked that information on the physical form. The PS was retrained to ensure that all sections of the physical form are properly completed ((CARES will review all individual physical examinations to ensure compliance. If any required information is found missing on a physical examination, CARES will contact the individual's physician to obtain the required information. The review will be completed by 12/1/19 -CH 10/22/19)) 10/03/2019 Implemented
2380.181(f)Assessments were not sent 30 days prior to ISP meetings. Individual #1's ISP meeting was held o 12/7/2018 and his assessment wasn't completed until 12/1/2018. Individual #2's ISP meeting was held on 3/15/2019 and her assessment wasn't completed until 3/5/2019 (Repeat Violation: 10/5/2018).The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The program specialist was retrained on the process of assessments for the 2380 regulations. Care will ensure that we are compliant with the 30 day rule 10/03/2019 Implemented
SIN-00142767 Renewal 10/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The fire drill that occurred on 3/29/18 had a recorded evacuation time of 2 minutes and 43 seconds. The fire drill that occurred on 5/30/18 had a recorded evacuation time of 2 minutes and 58 seconds. The facility does not have an extended evacuation time.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.On 3/29/2018 we had a VIP using the restroom and that delayed the evacuation time, and on 5/30/2018 the evacuation time was delayed because 2 VIP's went to exit the wrong exit and had to be redirected to use the proper exit location. In the future if we have a time exceeding the 2 and 1/2 minutes we will document the time and conduct another fire drill within that month to ensure that all VIP's can evacuate in the required timeframe. 11/01/2018 Implemented
2380.111(c)(7)The annual physical examination dated 5/30/18 for Individual #2 did not document the individual's health maintenance needs.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.We have made it a requirement that all VIP's in our program are utilizing our annual physical form. And if the physical is not returned completed we are resending the physical back to the caregiver. ((The physician for Individual #2 will be contacted to obtain the missing information -CH 12/7/18)) 11/01/2018 Implemented
2380.111(c)(8)The annual physical examination dated 5/30/18 for Individual #2 did not document the individual's physical limitations.The physical examination shall include: Physical limitations of the individual.As an agency we are having all VIP's utilize our annual physical documentation. If the physical does not have all sections completed we will be returning the documentation back to the care giver to ensure all sections are completed. The Program specialist Review Team will also be checking for areas left blank on physical forms if the Program Specialist misses sections. ((The physician for Individual #2 will be contacted to obtain the missing information -CH 12/7/18)) 11/01/2018 Implemented
2380.111(c)(9)The annual physical examination dated 5/22/18 for Individual #1 did not document allergies.The physical examination shall include: Allergies or contraindicated medication.As an agency we are having all VIP's utilize our annual physical documentation. If the physical does not have all sections completed we will be returning the documentation back to the care giver to ensure all sections are completed. The Program specialist Review Team will also be checking for areas left blank on physical forms if the Program Specialist misses sections. ((The physician for Individual #1 will be contacted to obtain the missing information -CH 12/7/18)) 11/01/2018 Implemented
2380.111(c)(10)The annual physical examination dated 5/30/18 for Individual #2 did not document medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.As an agency we are having all VIP's utilize our annual physical documentation. If the physical does not have all sections completed we will be returning the documentation back to the care giver to ensure all sections are completed. The Program specialist Review Team will also be checking for areas left blank on physical forms if the Program Specialist misses sections. ((The physician for Individual #2 will be contacted to obtain the missing information -CH 12/7/18)) 11/01/2018 Implemented
2380.111(c)(11)The annual physical examination dated 5/30/18 for Individual #2 did not document the individual's special dietary needs.The physical examination shall include: Special instructions for an individual's diet.As an agency we are having all VIP's utilize our annual physical documentation. If the physical does not have all sections completed we will be returning the documentation back to the care giver to ensure all sections are completed. The Program specialist Review Team will also be checking for areas left blank on physical forms if the Program Specialist misses sections. ((The physician for Individual #2 will be contacted to obtain the missing information -CH 12/7/18)) 11/01/2018 Implemented
2380.181(e)(12)The annual assessment dated 1/10/2018 for Individual #1 did not contain 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.This section of the annual assessment will be reviewed by Program Specialist prior to reviewing the Assessment with the team. ((The assessment for Individual #1 will be updated to include the missing information -CH 12/7/18)) 11/01/2018 Implemented
2380.181(f)The annual assessment dated 1/10/18 for Individual #1 was not provided to the SC and team members at least 30 calendar days prior to the ISP meeting which was held on 1/11/18.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 agency has created a Assessment distribution form to track when all assessments are submitted to the SC and what method of distribution was utilized. We have created a file review team consisting of Program Specialists to spot check other location files to ensure that required documents that are time sensitive are being completed in a timely manner. 11/01/2018 Implemented
SIN-00124152 Renewal 12/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2's annual physical exam was late. She had one on 12-22-15, then not again until 01-12-17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialist will monitor annual physicals for VIP's and ensure that they are being completed annually. A spreadsheet has been created that reflects when physicals are due for all VIP's in the program. The spreadsheet will be monitored by the Program Specialist. . 12/06/2017 Implemented
2380.111(c)(3)There was no indication on either Individual #1's or Individual #2's physical forms that either individual is current on her immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Program Specialist was retrained to ensure that all areas of the physical form need to be completed when they receive them from families/caregivers. ((Individual #1 received TDap on 12/6/2017 - CH 2/6/2018)) 12/06/2017 Implemented
2380.113(a)Staff #1's physical was late. She had one on 10-19-15, then not again until 11-09-17.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Program Specialist has obtained a staff physical list from the HR department and is tracking employee physicals with HR to provide a two step process of insuring physicals are completed in the required time frame. 12/11/2017 Implemented
2380.113(c)(2)Staff #1's TB test was late. She had it on 10-19-15, then not again until 11-13-17.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.Program Specialist has obtained a staff TB test list from the HR department and is tracking employee TB tests with HR to provide a two step process of insuring physicals are completed in the required time frame. 12/11/2017 Implemented
2380.181(a)Individual #2's annual assessment was late. She had one completed for her on 02-03-16, then not again until 04-03-17.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Cares developed a spreadsheet that illustrates when VIP's annual assessments are due to prevent missing a required date for an assessment in the future. ((VIP is the term used for individuals receiving services in a CARES facility - CH 2/6/2018)) 12/11/2017 Implemented
SIN-00104061 Renewal 12/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1 was admitted to program on 11/18/2015. He didn't receive initial fire safety training until 12/4/2015. 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.The agency will ensure that all Individuals starting the program will receive their initial fire safety training on the first day of program. This will be monitored by use of the Day Program Licensing Checklist document that has been updated on 12/7/2016. 12/07/2016 Implemented
2380.181(a)Individual #3 was admitted to the program on 7/11/2016. She didn't have her initial assessment until 9/20/2016, which exceeds the 60 day requirement.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.After the inspection a review of this licensing requirement was reviewed with the program specialist, to ensure that she understands that the assessments need to be completed within the first 60 days. In the future all Annual Assessments for new individuals will be completed within the first 60 of program start. I will be conducting book audits and by utilization of the Day Program Licensing Checklist document. 12/07/2016 Implemented
2380.186(c)(2)Reviews of ISP areas such as health and safety are not being completed in the ISP Reviews for Individual #1, Individual #2, Individual #3, and Individual #4.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.On December 7, 2016 during the inspection I, Korey Ebert made the correction to our Agencies, Case Review Form. I reviewed the corrected document with Maureen Timlin and obtained her approval on the document. The document was immediately forwarded to all of the Programs that CARES operates. From that date forward this form is being utilized by all programs to correct this issue. The form includes Individual ISP Reviewed for Accuracy and Any Content Discrepancy. 12/07/2016 Implemented
SIN-00082693 Renewal 10/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #1 was hired on 10/31/2014. Agency requested a criminal history from the PA state police on 12/2/2014. Staff #2 was hired on 10/27/2014. Agency requested a criminal history from the PA state police on 11/6/2014.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.Human resources will obtain a request for criminal history from the PA State Police within 5 days after the person's date of hire. 11/30/2015 Implemented
2380.111(a)Individual #1 was admitted to the program on 12/22/2014. Individual #1s record contained only one physical dated 8/18/2015. Individual #2 had a physical completed on 3/24/2014 and again on 4/30/2015. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The program specialist will obtain a current physical from each individual upon admission. The program specialist will review files quarterly to ensure annual physicals are completed before becoming overdue. The program specialist will review all other individual's files to ensure physicals are not overdue. 11/30/2015 Implemented
2380.181(a)Individual #2's assessment was completed on 12/23/2013 and again on 1/27/2015. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.the program specialist will complete initial assessment within 30 calendar days of admission for individuals. The program specialist will review files quarterly to ensure assessments for individuals are completed prior to annual assessments being due. The program specialist will review all other individual's files to ensure their assessments are not overdue. 11/30/2015 Implemented
2380.181(e)(6) Individual #1s assessment dated 9/14/15 does not assess his ability to avoid and safely uses poisonous materials. 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 program specialist will review assessment upon completion to ensure all areas are correctly filled out and have not been missed; especially those sections questioning the use or avoidance of poisonous materials. the program specialist will review all other individual's files to ensure all areas of current assessments are correctly filled out. 11/30/2015 Implemented
2380.181(e)(10)Individual #1's assessment dated 9/14/2014 does not contain a lifetime medical history. Individual #3's assessment dated 3/30/2015 does not contain a lifetime medical history. Individual #4's assessment dated 6/8/2015 does not contain a lifetime medical history.The assessment must include the following information: A lifetime medical history.the program specialist will complete a lifetime medical history for the individual's initial assessment and will update it as needed upon receiving information at quarterly ISP reviews. The program specialist will review all other individual's files to ensure assessments contain a lifetime medical history. If not, a lifetime medical history will be compiled. 11/30/2015 Implemented
2380.181(e)(13)(i)The assessment dated 9/14/2015 for individual #1 does not contain the individual's health over the last 365 calendar days. The assessment dated 6/8/2015 for individual #4 does not contain the individual's health over the last 365 calendar days. 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 program specialist will collect information at quarterly ISP reviews about the individual's health and medical appointments. The program specialist will add this information to the annual assessment. The program specialist will review all other individual's files to ensure assessments contain a summary of the individual's health over the last 365 calendar days. If not, a summary will be compiled. 11/30/2015 Implemented
SIN-00263824 Renewal 04/03/2025 Compliant - Finalized
SIN-00240664 Renewal 04/25/2024 Compliant - Finalized
SIN-00068794 Initial review 10/01/2014 Compliant - Finalized