Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286861 Renewal 05/04/2026 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.32(b)(1)Per ODP Announcement-20-114 staff working for 2380's must complete the standard medication administration training after 7/31/22. The modified medication administration was no longer sufficient for med training. All staff working at the 2380 completed the modified medication administration training. Subsequently leaving the day program with no staff who have successfully completed medication administration training.The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Implementation of policies and procedures.The chief executive officer is responsible for the administration and general management of the facility, including Medication Management Training. The CEO will assign and have oversight with Medication Management Training and will continue to monitor all policies and procedures including training requirements. The following timeline has been created between the CEO and Director of Programs for medication administration training requirements and compliance. May 2026: 3 staff June 2026: 1 staff July 2026: 1 staff August 2026: 1 Staff September 2026: 1 Staff 05/18/2026 Accepted
2380.84An inspection by a fire safety expert has not been completed to date.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.Program Manager contacted the fire department chief on 5/12/2026 to schedule a fire safety inspection. The provider heard back from the chief that they are a volunteer fire chief and does not do fire safety expert inspections. They directed the provider to the PA Municipal Code Alliance Office. This office was contacted on 5/14/2026, Program Manager left a message and did not have a return call. Program Manager called again on 5/18/2026 and was informed that an application must be submitted prior to scheduling, Program Manager received the application via email and returned immediately. Program Manager called back and confirmed that the application was received. The Program Manager was informed that the provider would receive a call to schedule the inspection. Program Manager again called back to request a scheduled day and time and was informed that they will email an invoice by 5/21/2026 and once that is paid, the inspection can be scheduled. 05/18/2026 Accepted
2380.89(b)There is no way to tell if the fire drills are being conducted during normal staffing conditions. The fire drill documentation does not identify staff that participated in the drill.Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average.Staff have been retrained to notate what staff were present during fire drills. The fire drill format has been updated to include this information. 05/14/2026 Accepted
2380.89(e)All the fire drills conducted from 9/2025 through present used the main exit as the exit route and no alternative exits were used.Alternate exit routes shall be used during fire drills.Staff have been retrained to utilize alternate exits in addition to the main exit when conducting fire drills. A staff member will hold a paper that has a photo of flames on it to help individuals process which exit to utilize during a drill. 05/14/2026 Accepted
2380.89(g)Fire drills conducted from 9/2025 through present did not document if all individuals made it safely to the meeting place.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The Program Manager confirmed with staff that were present during fire drills over this past fiscal year that all made it to the meeting place promptly and safely and retrained all staff that this must be documented on future drills. 05/14/2026 Accepted
2380.89(h)None of the fire drills conducted from 9/2025 through the present documented the detectors were set off.A fire alarm shall be set off during each fire drill.The current fire drill states if the smoke detectors were operatable but not if the worked/sounded and were set off during the drill. Program Manager confirmed with staff that during all drills that the alarm sounded, the detectors were operatable and the fire drill form was updated to reflect this information. 05/15/2026 Accepted
2380.111(c)(4)Individual #2's most recent physical completed on 3/30/26 did not screen for hearing.The physical examination shall include: Vision and hearing screening, as recommended by the physician.A letter was created and was sent to the individual #2's team specifying that this information is required and asking that this information be provided as soon as possible by the physician. 05/14/2026 Accepted
2380.111(c)(7)Individual #2's most recent physical completed on 3/30/26 does not document the health maintenance needs. This section was left blank. Individual #3's 09/02/25 Physical Examination Form does not include a review of "health maintenance needs"; this section of the form is 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.A letter was created and was sent to the individual #2's team specifying that this information is required and asking that this information be provided as soon as possible by the physician. 05/14/2026 Accepted
2380.111(c)(9)Individual #2's most recent physical completed on 3/30/26 does not correctly document individual #2's allergies. Under the medication allergies it is blank and under general allergies it says NKDA. Individual #2 does have seasonal allergies.The physical examination shall include: Allergies or contraindicated medication.A letter was created and was sent to the individual #2's team specifying that this information is required and asking that this information be corrected to reflect NKDA in the designated areas on the physical form.. Also, requested that seasonal allergies be reflected under allergies on the physical form. 05/14/2026 Accepted
2380.111(c)(10)Individual #1's 12/23/25 Physical Examination Form does not include "information pertinent to diagnosis and treatment in case of emergency"; this section of the form is blank. Individual #2's most recent physical completed on 3/30/26 does not document "medical information pertinent to treat or diagnosis in an event of an emergency". It says to call 911 and follow company policy. Individual #3's 09/02/25 Physical Examination Form does not include "information pertinent to diagnosis and treatment in case of emergency" ; this section of the form is blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A letter was created and was sent to the individual #2's team specifying that this information is required and asking that this information regarding pertinent information specific to diagnosis and needed treatment/instructions in case of an emergency be provided as soon as possible by the physician. 05/14/2026 Accepted
2380.113(c)(1)Individual #1's 12/23/25 Physical Examination Form does not include a review of "Immunizations"; this section of the form is blank. Individual #3's 09/02/25 Physical Examination Form does not include a review of "Immunizations"; this section of the form is blank.The physical examination shall include: A general physical examination.A letter was created and was sent to the individual #1' and individual #3's team specifying that this information in regard to immunizations is required and asking that this information be provided as soon as possible by the physician. All other client files will be reviewed at the scheduled time of their quarterly assessment and teams will be contacted to request updated information if applicable. 05/14/2026 Accepted
2380.171(b)(1)Individual #2's demographic information does not include the address for the emergency contact.Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.Individual #2s demographic face sheet was edited to include the address for the emergency contact. Program Specialist confirmed that all required information is included and accurate on #2 and all additional client's demographic face sheet. Information was added or edited as applicable. 05/13/2026 Accepted
2380.171(b)(3)Individual #2's demographic information does not include the address for whom to contact for emergency medical consent.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.Individual #2s demographic face sheet was edited to include the address for whom to contact for emergency medical consent. After review, it was determined that the legal guardian/parent's address was in fact on the demographic face sheet; however, whom to contact in an emergency for medical consent was edited to be clear. Program Specialist confirmed that all required information is included and accurate on #2 and all additional client's demographic face sheet. Information was added or edited as applicable. 05/13/2026 Accepted
2380.173(1)(ii)Individual #1's record does not include a current height or weight. Individual #3's record does not include "Identifying Marks" this section of the form is marked "N/A" for "not applicable".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.A letter was created to be sent to the supports team for Individual #1 to request this information from the physician. All client files were reviewed to ensure that height and weight is notated with a current height and weight. Individual #3's information was edited under "Identifying marks" to include the word "None." All client files were reviewed to ensure that the wording is not "N/A" Information was edited as applicable. 05/13/2026 Accepted
2380.181(e)(7)Individual #3's 01/03/26 Assessment does not indicate if Individual #3 can "move away quickly" 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.Individual #3's assessment was edited and redistributed on 5/14/2026 to include information for this individual's ability to move away quickly from heat sources in addition to the information already present in the assessment about the ability to recognize heat sources. All individual assessments were reviewed (and updated as necessary) to reflect both the ability to recognize and move away from heat sources. 05/14/2026 Accepted
2380.181(e)(11)Individual #2's most recent assessment completed 4/10/26 does not indicate if a psychological is applicable. Individual #3's 01/03/26 Assessment does not include a "Psychological evaluation" or any indication that one does not exist.The assessment must include the following information: Psychological evaluations, if applicable.Individual #2 from 4/10/2026 and individual #3's assessment from 1/3/2026 were edited and redistributed to the team members to include that "Psychological: None" All other client assessments were reviewed and edited/redistributed if applicable. 05/14/2026 Accepted
2380.21(l)The provider did not hold conversations with individual #2 or Individual #3 relating to their preferred community participation and activities as required by ODP announcement 24-061.An individual has the right to make choices and accept risks.While the provide has had conversations about CPS Community preferred activities, the provider recognizes that this has not been documented. Individual #2 and #3's quarterly reports were edited and redistributed to the individual teams to reflect this information. All client quarterlies were reviewed and updated to reflect this information. Those quarterly reports were edited, redistributed as applicable. 05/14/2026 Accepted
2380.36(b)No Fire Safety training was provided for Staff #2-4.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program Management were under the impression that Human Resources conducted fire safety training during new hire orientation. The provider has changed this to ensure compliance to include that this training will occur at new hire by the Program Manager and will take place on site at the 2380 program. This training will be completed with the new hire prior to working as a DSP in the program and annually thereafter. All program staff were fire safety trained on 5/13/2026 and all records will be maintained. 05/13/2026 Accepted
2380.39(c)(4)There is no documentation that staff #1 completed training on recognizing and reporting incidents during the last training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The requirements of Recognizing and Reporting Incidents was reviewed with Staff #1 by both the Director of Programs as well as Human Resources. Staff #1 has been notified that this training must take place prior to 6/30/2026 for requirement and compliance for this current fiscal year. 05/12/2026 Accepted
2380.129(a)At the time of the inspection, none of the staff working for the day program were med trained. They all completed the Modified Medication Training Course, which is not an acceptable medication administration training for staff working at 2380's.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).All EIM requirements were followed and met. Adult Protective Services RON was completed as required as well. The provider immediately halted administering medications and individuals, and their teams were notified of the inability to administer medications immediately and until further notice to allow for time for certification for administration. Individuals that were impacted had their schedules adjusted to allow for timely medication administration by their residential staff. All 2380 Programs within the agency were reviewed to ensure compliance. No provider staff will administer medications, injections, treatments until certification to do so is properly maintained. 05/18/2026 Accepted
2380.183(b)Only two members of the individual's team, excluding Individual #3 and their designated persons, participated in the 03/04/26 Individual Support Plan (ISP) meeting.At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised.Because of the timing of Individual #3's scheduled ISP meeting, no additional provider staff were available to attend the ISP meeting. The provider understands the requirement of this in the future and will ensure that staffing is available for day program so that additional team members may attend an individual's meeting when applicable and necessary. In the future, the provider will ensure that three team participants are in attendance in addition to the individual and their designee attend the ISP meeting. 05/18/2026 Accepted
SIN-00269233 Renewal 07/18/2025 Compliant - Finalized