Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00132968 Renewal 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)The program specialist provided Individual #1's assessment, completed 5/17/17 to the plan team members on 5/26/17 for an annual ISP meeting on 6/21/17.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).Program Specialist Coordinator will review time frames with Program Specialists, highlighting the requirement of sending out vocational assessments 30 days prior to ISP meetings. Change to be made and implemented immediately for a one-year period: All assessments will be completed 120 days prior to the ARUD in order to allow for time to send the assessment to the plan team members 30 days prior to the ISP Annual Review meeting. Outlook notifications will be generated by Administrative Secretary 10 days prior to the annual assessment. Program Specialists will attach a cover sheet checklist to the completed Assessment and send to the Administrative Secretary for distribution. All current Program Specialists as well as any new hires, will be trained on regulatory Assessment timelines, by PS Coordinator and Director of Client Services. 04/19/2018 Implemented
2390.156(a)The program specialist completed an ISP review for Individual #3 on 9/1/17 and then again 2/12/18. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.Program Specialist, Kelly Newhouse completed an ISP Review for the 3-month period from 9/1/17 to 12/1/2017. The ISP Review meeting was held with Individual #3 and sent to the plan team on 4/17/2018 in order to correct the violation. Change to be made and implemented immediately for a one-year period: An excel chart was developed by Program Specialists, Program Specialist Coordinator, Director of Client Services and Administrative Secretary outlining dates of all ISP reviews. Using Outlook, a notification will be issued to each Program Specialist 5 days prior and again 5 days after a scheduled ISP review; which will occur at least every 3 months. Upon completion of ISP Review Meetings, Program Specialists will attach a cover sheet checklist to the completed ISP Review Packet and give to the Administrative Secretary for final review. The Administrative Secretary will verify the packet is complete and distribute the packet to the ISP team within 30 days. The excel chart is then updated. A completed ISP review packet consists of a quarterly review and 3 monthly progress notes reviewed and signed by the program Specialist and client. All current Program Specialists as well as any new hires, will be trained on regulatory ISP timelines, by PS Coordinator and Director of Client Services. 04/19/2018 Implemented
2390.156(b)Individual #3's ISP review completed 2/12/18 was not signed by the individual. (Repeated Violation-4/28/17, et al) The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.Program Specialist, Kelly Newhouse, reviewed the plan completed on 2/12/2018 with individual, Individual #3, on April 6, 2018. Individual #3 signed and dated the report. Change to be made and implemented immediately for a one-year period: An excel chart was developed by Program Specialists, Program Specialist Coordinator, Director of Client Services and Administrative Secretary outlining dates of all ISP reviews. Using Outlook, a notification will be issued to each Program Specialist 5 days prior and again 5 days after a scheduled ISP review; which will occur at least every 3 months. Upon completion of ISP Review Meetings, Program Specialists will attach a cover sheet checklist to the completed ISP Review Packet and give to the Administrative Secretary for final review. The Administrative Secretary will verify the packet is complete and distribute the packet to the ISP team within 30 days. The excel chart is then updated. A completed ISP review packet consists of a quarterly review and 3 monthly progress notes reviewed and signed by the program Specialist and client. All current Program Specialists as well as any new hires, will be trained on regulatory ISP timelines, by PS Coordinator and Director of Client Services 04/19/2018 Implemented
2390.156(d)The program specialist provided Individual #2's ISP review completed 1/2/18 to the plan team members on 2/5/18. The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Administrative Secretary will monitor excel chart daily. Notification will be sent to PS to ensure that all ISP review packets are sent out within 30 days. Program Specialist Coordinator will review time frames with Program Specialists, highlighting the requirement of sending out plan reviews within 30 days. 04/19/2018 Implemented
SIN-00113106 Renewal 04/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(b)Individual #1 did not sign the ISP reviews ending on 3-1-17, 12-2-16 and 9-1-16. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.The Director of Client Service and program specialists have developed a checklist to review monthly reports and quarterly reports for signatures prior to being mailed to team members and filed. The clerical staff who mails out reports will be responsible for double checking for signatures as part of our process. At the monthly program specialist meeting, Director of Client Services will review the checklist and determine the new process is being adhered to. Checklist will begin on 5/15/17 and follow up will continue for 3 months, May - August. [Individual #1 signed the ISP reviews ending on 3-1-17, 12-2-16 and 9-1-16 on 5/1/17. From 5/1-5/17, program specialists reviewed all individuals' ISP reviews to ensure the program specialist and individuals signed and dated ISP reviews as required. Documentation of Director of client services' reviews shall be kept. (AS 5/15/17)] 05/12/2017 Implemented
SIN-00093536 Renewal 04/25/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)Individual #1's most recent ISP reviews were completed on 3/13/15, 6/14/15, and 3/8/16. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.The new staff person will be given a copy of the 2390 regulations. He/she will be trained on the regulations and how the reports are to be done and documented in the client file. The staff person will receive training on how to do reports properly and ongoing monitoring will take place to ensure they are done according to regulations. Periodic on-going monitoring will take place during the year to maintain the correct procedures. Director of Client Services will do the training and monitoring. [Individual #1's ISPs reviews for 3 months periods ending September 9, 2015, December 9, 2015 and June 9, 2016 were completed 8/17/16; as well as, provided to the plan team members. Immediately, the Director of Client Services will review the program specialist job responsibilities as specified in 2390.33b 1-19. Documentation of the review shall be kept. Aforementioned "ongoing monitoring" by the Director of Client Services shall take place at least monthly for 1 year to ensure the program specialist is completing responsibilities including completing ISP reviews for all individuals within required time frames. Documentation of monthly ongoing monitorings shall be kept. (AS 5/6/16)] 05/06/2016 Implemented
SIN-00077897 Renewal 04/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.65The front and back interior stairs to the mezzanine level do not have a nonskid surface.Interior stairs shall have a nonskid surface.The nonskid pads are purchased and will be put on the stairs to the mezzanine by 5/22/15 by the building maintenance crew.[A picture of the front and back interior stairs with the nonskid pads will be submitted to the department via email to ascharpf@pa.gov by 7/15/15. (AS 5/26/15)] 05/23/2015 Implemented
2390.82(b)The two most recent on site fire safety inspections were held on 1/31/14 and 3/18/15.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.The facility coordinator reviewed the licensing requirements. Coordinator will make a reminder system to have the annual inspections scheduled and completed based on the date of the previous inspection so it falls within the "annual" requirements of the regulation. 05/23/2015 Implemented
2390.83(c)-2The facility did not have a written procedure for fire safety monitoring in the event that the fire alarm is inoperative.There shall be a written procedure for fire safety monitoring in the event that the fire alarm is inoperative.The policy was rewritten as of 4/7/15 to include a more specific plan if the fire alarm is inoperative. The new policy will be sent by mail to BHSL on 5/20/15. 05/23/2015 Implemented
2390.84(d)The main area had three fire extinguishers that were not mounted to the wall. Fire extinguishers weighing under 45 pounds shall be mounted on the wall so that the extinguishers are visible to staff and clients.All fire extinguishers will be mounted on the wall by 5/22/15 by the building maintenance crew. [A picture of the mounted fire extinguishers will be submitted to the Department via email to ascharpf@pa.gov by 7/15/15. (AS 5/26/15) 05/23/2015 Implemented
SIN-00054077 Renewal 03/06/2015 Compliant - Finalized