| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | The closet in the kitchen area that contained cleaning supplies was left unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The Center Director immediately locked the janitorial closet upon discovery of it being unlocked. |
08/27/2026
| Implemented |
| 2380.53(b) | There was a bottle with a blue substance in the closet where the cleaning supplies were kept that had "glass cleaner" handwritten on it. | Poisonous materials shall be stored in their original, labeled containers. | The Center Director immediately following the inspection retrieved the bottle with 'glass cleaner' handwritten on it and discarded the contents and threw the bottle in the trash. |
08/27/2026
| Implemented |
| 2380.55(a) | There was feces on the toilet seat in the men's bathroom. | Clean and sanitary conditions shall be maintained in the facility. | The Center Director immediately had the toilet seat cleaned. |
08/27/2026
| Implemented |
| 2380.67(a) | The freezer in the kitchen area had a buildup of ice that was more than an inch thick. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The Center Director instructed staff to defrost the freezer. |
08/27/2026
| Implemented |
| 2380.84 | The agency did not produce a fire inspection stating that they had previously used the City of Philadelphia but that they are no longer performing inspections for their building. | 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 Center Director immediately called different agencies to obtain a fire safety expert. |
08/24/2026
| Implemented |
| 2380.91(a) | There was no fire safety training in the program binder for the individual #2 | 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 Center Director and the nurse will have training binders in each of their offices that includes general fire safety, evacuation exits and the designated meeting space. See attached. |
08/31/2026
| Implemented |
| 2380.91(a) | There was no fire safety training in the program binder for the individual #4. | 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 Center Director and the nurse will have training binders in each of their offices that includes general fire safety, evacuation exits and the designated meeting space. See attached. |
08/31/2026
| Implemented |
| 2380.91(a) | There was no fire safety training in the program binder for individual #3. | 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 Center Director and the nurse will have training binders in each of their offices that includes general fire safety, evacuation exits and the designated meeting space. See attached. |
08/31/2026
| Implemented |
| 2380.91(c) | The provider's management information system acted as the written record for documenting general fire safety, evacuation exits, and the designated meeting space; however, no prepared content was used to educate the individuals or retained to identify the individuals trained. | A written record of firesafety training, including the content of the training and individuals attending, shall be kept. | The Center Director and the nurse will have training binders in each of their offices that includes general fire safety, evacuation exits and the designated meeting space. |
08/31/2026
| Implemented |
| 2380.111(a) | The annual physical examination form dated October 10, 2025 did not contain all the required components completed (review of previous medical history, immunizations, vision & hearing screenings, etc.) as outlined in the regulations for the individual #2. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Center Director obtained the completed physical which contains all the required components. Please see attached. |
08/27/2026
| Implemented |
| 2380.111(c)(6) | The Physical Examination & Health Assessment Form dated March 4, 2026 indicated that the individual #4 was not free of communicable diseases and did not "specify and include special precautions to prevent transmission". | 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 Center Director obtained clarification regarding the individual #4 'free of communicable disease'. See attached. |
09/01/2026
| Implemented |
| 2380.171(b)(1) | The program binder did not contain current emergency information for the individual #2. Staff explained that the mother, who is the legal guardian, of the individual deceased two weeks ago. | 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. | The Center Director contacted the individuals Supports Coordinator and was told that the Program Manager, Danielle Pierre, would be listed as the individual's emergency contact. See attached. |
08/27/2026
| Implemented |
| 2380.173(1)(ii) | The program binder face sheet did not contain height, weight, color of hair, and eye color for the individual #2. | 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 face sheet was printed from the EHR and placed in the individual's record. It contains the height, weight, color of hair, color of eye's and identifying marks. See attached. |
08/31/2026
| Implemented |
| 2380.173(1)(iv) | The program binder face sheet did not contain the religious affiliation for the individual #2. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Induvial #2's face sheet has been updated to include her religious affiliation. See attached. |
08/31/2026
| Implemented |
| 2380.173(4) | The program binder did not contain the assessment for the ISP dated August 12, 2025 for the individual #4. | Each individual¿s record must include the following information: Assessments as required under § 2380.181 (relating to assessment). | The Center Director and the Program Specialist contacted individual #4's SC to inquire about an ISP meeting on August 12th, 2025. The SC responded by sending an email reading there was only a home monitoring on that date. Please see attached. |
09/03/2026
| Implemented |
| 2380.173(4) | The program binder contained an email mentioning the assessment dated May 30, 2023. No other information for the most recent ISP meeting held on September 11, 2025 was found for individual #2. | Each individual¿s record must include the following information: Assessments as required under § 2380.181 (relating to assessment). | Individual #2's annual assessment is attached. |
09/01/2026
| Implemented |
| 2380.173(4) | The program binder did not contain the assessment for the ISP dated September 15, 2025 for individual #3 | Each individual¿s record must include the following information: Assessments as required under § 2380.181 (relating to assessment). | Individual #3's assessment completed on 8/25/2025. Please see attached. |
09/01/2026
| Implemented |
| 2380.177 | The program binder contained an undated Release of Medical Information the only had the initials of the individual #2's mother, who was recently deceased as of two weeks ago. | 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 Center Director will ensure that all forms are dated when forms are either signed or initialed going forward. |
08/28/2026
| Implemented |
| 2380.177 | The program binder contained a Release of Medical Information dated March 14, 2025 for the individual #4, which detailed that the "release form will remain in effect for 12 months from the date of signing." | 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 individual signed the updated Release of Medical information form. Please see attached. |
09/01/2026
| Implemented |
| 2380.177 | The program binder contained an undated Release of Medical Information for the individual #3 which detailed that the "release form will remain in effect for 12 months from the date of signing." | 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. | Individual #3 signed the new updated Release of Medical Information form with a date. Please see attached. |
09/01/2026
| Implemented |
| 2380.181(a) | Individual #1's annual assessment was unable to be accessed during the inspection. | 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. | Individual #1's annual assessment was completed in our EHR system (CADcare). Due to internet conductivity issues at the center, the inspector was unable to review. See attached. |
08/28/2026
| Implemented |
| 2380.21(a) | The program binder contained Individual Rights that were last signed on July 9, 2025 for individual #3. | An individual may not be deprived of rights as provided under subsections (b) - (q). | Individual #3 signed their Individual Rights on 4/13/2026. Please see attached. |
08/31/2026
| Implemented |
| 2380.37(a) | Staff #1's training record was not adequately represented by data other than dates. No certificates or official sign-in sheets were available. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | All training materials including certificates are maintained in our Learning Management System. |
08/31/2026
| Implemented |
| 2380.39(a)(1) | Staff #1 did not have 24 hours of training for the last completed calendar year of training.
Staff #2 did not have 24 hours of training for the last completed calendar year.
Also, staff #2 completed 14 hours of training on 2/24/26 which exceeds the recommended training for one day. When asked the director stated that staff was not financially reimbursed for the time spent in training.
Staff #3 had a total of 22 hours of training for the 2025 training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Directive service workers. | All staff will have required 24-hours of training. |
09/01/2026
| Implemented |
| 2380.173(5) | The program binder did not have an ISP meeting attendee sign-in sheet for the most recent ISP meeting held on August 12, 2025 for the individual #4. | Individual plan documents as required by this chapter. | The Program Specialist emailed the SC and the Supervisor to inquire about the meeting minutes for August 12th, 2025. The individual's enrollment date for Active Day is May 5th, 2025. No meeting invitation was received, or meeting was held at the center. |
09/01/2026
| Implemented |
| 2380.173(5) | The program binder did not have an ISP meeting attendee sign-in sheet for the most recent ISP meeting held on September 11, 2025 for the individual #2. | Individual plan documents as required by this chapter. | Individual #2 had an ISP meeting on 7/28/2025. Please see attached ISP sign in sheet and invite. |
09/01/2026
| Implemented |
| 2380.173(5) | The program binder did not have an ISP meeting attendee sign-in sheet for the most recent ISP meeting held on September 15, 2025 for individual #3. | Individual plan documents as required by this chapter. | An invitation was not sent to the Program Specialist or the Center Director for September 15th, 2025. An invitation letter was sent on February 4th, 2025, and ISP meeting was scheduled for March 17th, 2025, for individual #3. |
09/01/2026
| Implemented |
| 2380.182(c) | Individual #1's current plan does not reflect the day program's understanding of the individual's current needs as stated by staff #4 during the inspection process. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Center Director and the Regional Director reviewed the ISP and found that the W7224 service code reflected the care provided according to individual # 1's ISP. The SC also confirmed that individual #1 is a 1:2-1:3. Please see attached email communication from individual #1's SC. |
09/01/2026
| Implemented |
| 2380.186 | Repeat Citation: Repeat citation: During licensing individual #1 was observed having little or no supervision by licensing staff. The individual came in and out of the meeting room without staff's knowledge or supervision. Individual #1 was exhibiting self-stimulating behaviors in the room with licensing. Individual #1's current ISP states that the current level of supervision is 1 to 1. | The facility shall implement the individual plan, including revisions. | Individual #1's ISP reads that he is a 1:2- 1:3 ratio in the facility (center) and he is a 1:1 in the community (CPS). The service code W7224 which is in the ISP and what ODP pays the facility matches what service the center is providing. |
08/26/2026
| Implemented |