Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00272027 Renewal 08/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)At the time of the inspection bathroom #1 was unlocked and had the following poisons accessible, Listerine Mouthwash, Equate mouthwash, Prescribed mouthwash Chorhex Glu Sol 0.12%, One step disinfectant and hand soap..Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.At the time of inspection, bathroom 1 was unlocked and had the following poisons accessible: Listerine mouthwash, Equate mouthwash, prescribed mouthwash Chorhex Glu Sol 0.12%, and one step disinfectant and hand soap. 55 PA Code Chapter 2380.53(a) ¿ Poisonous materials shall be kept locked or made inaccessible to individuals when not in use. New hand soap was purchased (Scott Green Certified Foam Skin Cleanser) for all bathrooms, changing rooms, and program rooms that have sinks. Previous soap in the bathroom was not non-toxic. All poisons were removed from the bathroom. All poison in ATF are locked when not in use. All ATF staff were trained on 55 PA Code Chapter 2380.53(a) ¿ Poisonous materials shall be kept locked or made inaccessible to individuals when not in use on 8/22/2025. See attached sign in sheet, Attachment # 1. 09/12/2025 Implemented
SIN-00249893 Renewal 08/20/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186Individual # 1's utilizes a wheelchair for mobility. ISP dated 08/12/24 reads "Individual # 1 has a history of open areas. Staff offer a change of position a minimum of every 2 hours." There is no documentation that staff are offering a change of position a minimum of every two hours as written in the ISP.The facility shall implement the individual plan, including revisions.Training will be completed by September 10th, 2024 with the ATF staff who are responsible for documenting positioning. Training will be conducted by Program Director. 55 PA Code Chapter 2380.186 The facility shall implement the individual plan, including revisions Completed documentation will be submitted monthly. 09/10/2024 Implemented
SIN-00228891 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.67(a)The right door on the storage in cabinet in classroom # 4 was broken at the time of the inspection. The door came completely off the hinges when it was opened.Furniture and equipment shall be nonhazardous, clean and sturdy.The right door of the cabinet in classroom #4 that was broken at the time of the inspection was removed to avoid a hazardous situation. A new cabinet was ordered as a replacement on 8/15/2023 (please see attachment #1). The new cabinet was received and placed in the classroom on 8/28/2023 (please see attachment #2). 08/30/2023 Implemented
2380.181(d)Individual #1's assessment with start date of 5/11/23 and sent date of 6/14/23 does not include the program specialist's signature.The program specialist shall sign and date the assessment.Program Specialists were trained on this regulation 7/6/23 (See attachment #4). Attachment #4 is the training session that was held that included the importance of the Program Specialist signing and dating the assessment prior to sending the assessment out to the team members. Individual #1¿s Assessment was signed and dated on 9/6/2023 (See attachment #5) 09/06/2023 Implemented
2380.181(d)Individual #2's assessment with start date of 2/6/23 and sent date of 6/2/23 does not include the program specialist's signature.The program specialist shall sign and date the assessment.Program Specialists were trained on this regulation 7/6/23 (See attachment #4). Attachment #4 is the training session that was held that included the importance of the Program Specialist signing and dating the assessment prior to sending the assessment out to the team members. Individual #2¿s Assessment was signed and dated on 9/6/2023 (See attachment #6). 09/06/2023 Implemented
2380.173(5)Individual #1's record included an ISP dated 6/20/22, which is not the most current. The Individual's most recent ISP is dated 7/11/23.Individual plan documents as required by this chapter.The most recent ISP dated 7/11/23 for individual #1 was included in the individuals record on 8/15/2023 (See attachment #7). 08/15/2023 Implemented
2380.181(f)Individual #2's assessment was completed on 6/2/23. The annual ISP review meeting was held on 6/7/23. The assessment was not completed and sent to the Supports Coordinator at least 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Provider realizes that this violation cannot be corrected for Individual #2 07/06/2023 Implemented
SIN-00205599 Renewal 05/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)There were no strobes in classroom # 1, Classroom # 2 or the Lunch Room.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.As Merakey Allegheny Valley School re-opens the ATF, the interdisciplinary team (IDT) will review the hearing ability of each individual and the team will make recommendations to which classroom the individual can be placed. Example: If the individual is hard of hearing they will be placed in a classroom with a strobe light. The IDT has reviewed all current individuals that have returned to in-facility day services and noted their hearing status in the Mini IDT documentation by Program Specialist (Sample Individuals #1 & 2). Individuals that attend the Merakey AVS Hummelstown ATF participate in their assigned classrooms throughout the day including lunch. They do not eat in the dining room. However, there is a strobe light positioned immediately outside the dining room door. During fire drills all individuals are informed of the pending drill via their form of communication. All individuals require physical assistance of 1:1 staff to safely exit the building. Training completed by Communication Specialist detailing the process of team meetings to review hearing status of individuals attending and/or returning to Hummelstown ATF. Training was conducted for program and social services staff(Attachment #5). Completion Date: 6/14/2022 06/14/2022 Implemented
2380.171(b)(3)Individual # 2's face sheet does not include the name of the person who can provide emergency medical consent. It lists next of kin only.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.The electronic record Face Sheet has been formatted to include the addition of an Emergency Contact/Contact for Emergency Consent for Treatment section. The interim Social Services Supervisor completed a training of social services staff on how to complete and pull Face Sheets in the electronic record on 6/14/2022. Specific training on AVATAR Personal Contacts was completed so the document pulls to Next of Kin and Emergency Contact/Emergency Consent for Treatment¿ in the client Face Sheet (Attachment #1 Staff Acknowledgement Sheet). Both individual #1 and #2 were corrected (Attachment #2 and #3). All individuals Face sheets were updated and given to program director for filing on this date 6/14/2022. Completion date: 6/14/2022 06/14/2022 Implemented
2380.176(a)Individual assessments were in a filing cabinet unlocked and unattended in classroom # 2. A form with individual names and medical appointments was left unlocked and unattended in classroom # 5.Individual records shall be kept locked when they are unattended.The week of June 6, 2022, all program classrooms were reviewed and if discovered identifying information was removed and shredded. The Program Director completed a re-training of 2380.176 (a) on 6/8/2022 with staff signing Staff Attendance Sheet (attachment #6). Training consisted of reinforcement of any documents that contained names of individuals must be locked prior to leaving the classroom. The program director observed each classroom on 6/14/2022 for any information left out unattended and found no violations. Program director and/or assistant program manager will complete weekly checks for one month (June 2022) and monthly checks for two months (July/August 2022). Checks will be documented and kept in the plan of correction file. If there would be any future violations, information will be immediately locked, and staff re-trained by the program director or assistant program manager. Completion date: 6/14/2022 06/14/2022 Implemented
SIN-00129486 Renewal 03/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical dated 01/19/2018 and Individual #4's physical dated 01/12/2018 did not include: 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.Allegheny Valley School acknowledges that an area was left blank on the physical form for individual A.C. The doctor reviewed his physical form on 3/27/18 and filled in the blank to include doctor signature and date (attachment #3). To assure there is no recurrence the Program Director met with Waiver nursing staff on 3/28/18. A training will be completed by Waiver nursing staff with all House Managers by April 11, 2018 on procedures to ensure all areas of the physical form is completed by the physician. In addition to this training the Program Director will review all physical forms to ensure all blanks are completed prior to filing form in individuals¿ ATF chart. Program Director will begin this review April 2, 2018 through March 29, 2019. If a blank on a physical form is found the Program Director will immediately notify the Waiver Administrator, House Manager and Waiver nursing to appropriately correct physical form. Additionally, any re-training of the house manager will be conducted at that time and documentation will be on file in the Program Director¿s office. 04/11/2018 Implemented
2380.186(c)(2)Individual #3's ISP reviews dated 01/30/2018, 10/30/2017, 07/28/2017, and 04/28/2017 did not review the seizure protocol.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Allegheny Valley School acknowledges that there is no documentation regarding seizure activity in the ATF quarterlies for Individual #1. However, seizure monitoring is documented quarterly in his residential quarterly reviews. To prevent recurrence and to include all individuals that attend the ATF, Program Director will re-train program instructors/Program Staff to include seizure activity in their monthlies and quarterlies. This training was completed by the Program Director by April 2, 2018 (Attachment #1). The Social Services Supervisor will re-train the Program Specialist to include seizure monitoring information in ATF quarterly reviews by April 4, 2018 (Attachment #2). Additionally to insure there is no recurrence the Program Director will review the quarterly documentation for Individual #1. prior to filing in his ATF chart for the next two quarterly reviews (six-month period). Program Director will initial last page of quarterly as an indication that review is completed. If the Program Director discovers documentation is not included in the quarterly review Program Director will notify the Social Services Supervisor and appropriate follow up action will be determined and documentation of the intervention will be kept in the Program Director's office. 04/11/2018 Implemented
SIN-00105021 Renewal 01/24/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff # 2 had criminal history record check requested on 03/29/16. Staff # 2's date of hire was 02/02/15. Criminal history record check was not completed within 5 working days after date of hire. 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.Allegheny Valley School acknowledges that a staff person hired in 2005 to one department then transferred to program within the same agency in 2015. Updated criminal record check for the time of transfer was not available, however, according to 20 (a) no checks are required if an employee transfers positions within the same agency. 02/07/2017 Implemented
2380.176(a)A stack of individual records was sitting on top of the filing cabinet unattended and unlocked in the Occupational Therapy room. Individual records shall be kept locked when they are unattended.Allegheny Valley School acknowledges records were on top of filing cabinet in therapy room. Door locks have been installed for the therapy room and room will be locked when unattended. 02/07/2017 Implemented
2380.177Individual #1's record did not include consent for information released. 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.Program Specialist will telephone individual¿s family contact to gain release of information as well as meet with individual to gain release of information. The Program Director will review all charts to insure appropriate consents are present by March 2, 2017. As a preventative measure, the Program Director will add a review of consent section of individuals¿ files to the regular quarterly chart audit procedure for the next 6-months. 03/02/2017 Implemented
2380.186(c)(1)Individual # 1's Individual Support Plan (ISP) quarterly signed 01/27/16 did not include monthly reviews of 10/15, 11/15 and 12/15 participation and progress in community integration. The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Electronic record has been reformatted to include month specific activities. All staff have been in-serviced on electronic record in February 2016. As a preventative measure, the Program Director will add a review of reformatted section of quarterly reviews to the regular quarterly chart audit procedure for 6-months. If any concerns are discovered at the time of the review will be reported to the AVATAR Help Desk and the Program Director will keep a copy of the report/resolution. 03/02/2017 Implemented
2380.186(c)(2)Individual # 1 did not participate in community integration outings during the quarter 10/28/15-01/27/15. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Staff will be re-trained on documenting ISP specific sections including community integration activities and note details of any rescheduling due to weather, medical appointments etc. As a preventative measure, the Program Director will add a review of the program quarterlies to regular quarterly chart audit procedure for 1 year. All quarterlies will be reviewed and any concerns found will be discussed with the program instructor and program specialist. Re- training will be completed as deemed necessary. 02/28/2017 Implemented
SIN-00086364 Renewal 01/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(9)Individual #4's physcial dated 9/15/15 states allergies as NKA and ISP states seasonal allergies/rhinitis and is currently taking Allegra 60mg and Astelia 137 mcg. The physical examination shall include: Allergies or contraindicated medication.Allegheny Valley School acknowledges that the following allergies (Allergic Rhinitis/seasonal allergies) were noted in the Individual Support Plan but not noted on the Allergies/Drug Reactions section of physical examination form dated 9/15/15, however, both diagnosis were documented on page 2 of physical under Diagnostic Impressions (attachment #1). On 1/20/16 the doctor was contacted and reviewed individual¿s physical examination section Allergies/Drug reactions. The doctor wrote an order on 1/20/16 adding the following diagnosis to the Allergies/Drug Reactions section: allergic Rhinitis/seasonal allergies (attachment #2). The individual¿s physical examination was updated per doctor¿s order by nursing on 1/27/16 (attachment #3). To assure there is no recurrence, at the Individual Support Plan (ISP) meeting for all individuals the Allergies/Drug Reaction section will be reviewed by nursing along with the team to insure all allergies or contraindicated medications are documented correctly per doctor¿s recommendation. Correction date: 1/27/16 02/03/2016 Implemented
SIN-00045085 Renewal 01/30/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(6)(i)There are no copies of ODP Team member signature sheets for initial/annual ISP Planning Meetings in Individuals' # 1, 2. 3 and 4's records (6)  A copy of the signature sheet for: (i)   The initial ISP meeting.Partially Implemented - Adequate Progress The Program Director will insure each ISP has a signature sheet for the annual meeting. A copy of the signature form will be received from the Program Specialist. Program Director will audit to verify a signature sheet is filed with the ISP in the individual's chart.Initial audit will be conducted to insure all individual's charts have an ISP signature form. Audit will be completed by 3/28/13 by the Program Director. Attached are signature sheets for the individuals from the Inspection sample on 1/30/13 and 1/31/13. The Social Services Supervisor will train the Program Specialist on the procedure to give the Program Director a copy of the ISP signature form. Training will be verified by written documentation of signatures of all staff on Staff Attendance Sheet. the Staff Development Facilitator will confirm via Staff Attendance Sheets that all pertinent staff have received the training. 03/28/2013 Implemented
2380.181(c)The annual assessment formats for all Individuals, # 1, 2, 3 and 4 are missing The Basis for Assessment. (c)  The assessment shall be based on assessment instruments, interviews, progress notes and observations.Partially Implemented - adequate Progress The Program Director will insure that assessments are based on assessment instruments, staff and individual interviews, oberservations, and progress notes. Program Director will complete monthly audits of the ISP meeting process for the next year. The audits will follow the schedule of the annual ISP meetings. Audit documentation will consist of verification of collaborative input of team members and all information reviewed at ISP meeting and supports and services are agreed upon during the team meeting. 03/28/2013 Implemented
SIN-00216964 Unannounced Monitoring 01/05/2023 Compliant - Finalized
SIN-00186493 Renewal 04/19/2021 Compliant - Finalized
SIN-00146220 Renewal 02/07/2019 Compliant - Finalized
SIN-00071243 Renewal 02/12/2015 Compliant - Finalized
SIN-00060129 Renewal 01/29/2014 Compliant - Finalized