Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274010 Renewal 09/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)On 9/18/2025 at 2:35PM, an aerosol spray bottle of Claire Disinfectant Spray was unlocked and accessible on a shelf in the bathroom in the hallway near the entrance of the facility. At 3:04PM, a bottle of Acetone Nail Polish Remover was unlocked and accessible in a cabinet in program area four.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The can of Claim Disinfectant Spray was removed from the staff bathroom and locked in the Janitor's closet. The bottle of Acetone was removed from cabinet and locked in the janitor's closet. Both were removed and locked on 9/18/2025. 09/18/2025 Implemented
2380.55(a)At approximately 3:00PM, in Program Areas Two, Three and Four, the microwaves contained splatters of food particles on the inside and areas of delamination on the inside and outside.Clean and sanitary conditions shall be maintained in the facility.The microwaves in Program Areas Two, Three and Four were removed on 09/19/2025, prior to any further use of these microwaves. Three new microwaves were purchased on 9/23/2025 and placed in Program Areas two, three and four. 09/19/2025 Implemented
2380.111(c)(1)Individual #1's annual physical examination, completed 8/27/2025, did not include a review of previous medical history. Individual #4's annual physical examination, completed 7/17/2025, did not include a review of previous medical history.The physical examination shall include: A review of previous medical history.Unfortunately, The physical cannot be corrected as it is too far passed the date of the physical. Individual # 1 lives in a group home with another agency. The physical was completed on 8/27/2025, but we do not know the day it way received. NAME REMOVED Program Specialist requested more information regarding the lines that indicate see MAR. On 9/17/25, NAME REMOVED received a copy of the September 2025 Therap Mar via e-mail. This provided us with a current list of diagnosis's , medications, allergies and dietary guidelines. Individual #4 lives with his family and they did not provide any additional information with the physical form. See below for future corrective action. 10/01/2025 Implemented
2380.21(u)Individual #1 was informed and explained individual rights on 2/5/2024 and then again on 2/6/2025. Individual #2 was informed and explained individual rights on 6/12/2025. Individual #3 was informed and explained individual rights on 2/6/2025. Individual #4 was most recently informed and explained individual rights on 9/1/2024. Individual #5 was informed and explained individual rights on 7/23/2024 and then again on 7/30/2025. The provider agency's current individual rights document did not include: 2380.21c, an individual may not be reprimanded, punished or retaliated against for exercising the individual's rights; 2380.21g, an individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.2380.21U- For this regulation we will now explain and have the individual or guardian sign the 2 times per year to keep us in compliance. Our past practice was to have these signed at the Individual's ISP Meeting. 2380.21g- The Individual rights form was updated on 9/22/2025. A statement was added to the top, AN INDIVIDUAL MAY NOT BE DEPRIVED OF HIS RIGHTS. Also added was a new #1 stating: AN INDIVIDUAL MAY NOT BE REPRIMANDED, PUNISHED, OF RETALIATED AGAINST FOR EXERCISING INDIVIDUAL'S RIGHTS. And a new #2: AN INDIVIDUAL HAS THE RIGHT TO DESIGNATE PERSONS TO ASSIST IN DECISION-MAKING AND EXERCISING RIGHTS ON BEHALF OF THE INDIVIDUAL. The policy and procedure was also updated by the compliance officer, NAME REMOVED. 09/22/2025 Implemented
2380.36(a)Direct Service Worker #1, date of hire 6/23/2025, was trained in general fire safety on 6/23/2025. This training did not include site specific 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.On 9/19/2025 we received additional documentation from our HR department on DSP #1. This document shows that she had training in the following areas: evacuation procedures; responsibilities during fire drills; designated meeting place; smoking safety procedures; use of fire extinguishers; use of smoke detectors; use of fire alarms. The documentation contains a summary of general fire safety. It also lists the following copies of policy and procedures she received; Evacuation policy and procedure; smoking safety policy and procedure and policy for monitoring when the alarm is inoperable. DSP#1 will be attending the Annual fire safety training for staff on 10/3/2025. 10/03/2025 Implemented
2380.123(h)Individual #2's prescribed medication, Acetaminophen, had an expiration date of 5/2025.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to applicable Federal and State statutes and regulation.Individual #2 mother was contacted on Friday 9/19/2025 regarding expired bottle. The bottle and medication was sent home with Individual #2 on Friday 9/19/2025. On Monday 9/22/2025 a new bottle of acetaminophen was received with an expiration date of 12/2026. 09/22/2025 Implemented
2380.126(a)(11)Individual #1's September 2025 Medication Administration Record did not include the diagnosis or purpose for Bethanechol 10MG. Individual #5's September 2025 Medication Administration Record did not include the diagnosis or purpose for Tylenol 500MG and Clonazepam.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1 September 2025 MAR had the diagnosis of urinary retention added on the left hand side under the name and instructions for Bethanechol 10mg on 9/19/2025 before the time of administration. Individual #5 September 2025 MAR had the diagnosis of tone/spasticity added on the left hand side under the clonazepam dosage and instructions on 9/19/2025 before the time of administration. The purpose for the Tylenol, pain, was added to the September MAR under the dosage and instructions on 9/19/2025 before the time of administration. 09/19/2025 Implemented
SIN-00253878 Renewal 10/10/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1, date of admission 10/22/18, had an annual physical examination completed on 05/18/23 and then again on 06/11/24. This exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Each individual, parents, provider or caregiver is sent a packet of information during the third month prior to the physical due date. The packet contains a letter listing the 2380.11a regulation, the date of the last physical and the date the new physical is due. The letter also contains the last Tetanus date and the next due date plus the Mantoux date. The letter also states that failure to have the physical completed by the due date will result in a disruption of supports and services until the physical is complete. Also in the packet is the physical form and a Verification of Scheduled Annual Physical form, that is to be filled out and returned. A master list of physical dates is kept and updated as physicals are completed. The CPS director checks the list at least every 15 days and alerts the Program Specialist when physicals are coming due. The Program Specialist then calls the appropriate person to make sure the physical is scheduled, If the Verification Of Scheduled Physical form has not been returned. 10/23/2024 Implemented
2380.113(c)(3)Direct Support Professional #1, date of hire 05/06/24, had a physical examination completed on 09/09/23, which did not include a signed statement to indicate the person is free of communicable disease.The physical examination shall include: A signed statement that the person is free of serious communicable diseases 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, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.The physical exam in question was completed on a form used by Med express and not on the Whole Life Physical form. Beginning today all new hires in licensed facilities, will be required to have their physicals completed on the Whole Life Services Staff Physical form. This will also be required for all biennial staff physicals. The Human Resource Director and/or her assistance will check each physical prior to the new hire¿s start date to assure that all the information is correct. 10/23/2024 Implemented
2380.181(a)Individual #2, date of admission 03/06/02, had an annual assessment completed on 08/12/22 and then again on 11/14/23. This exceeds the annual 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.A master list of Assessment dates has been created, so the date of assessment can be easily found by all the Program Specialists. The Program Specialist will be responsible for the annual assessment of each person on their caseload. At the end of each month, each Program Specialist will be responsible to look at the master list of assessment dates and note the assessments due in the up coming month. 10/24/2024 Implemented
SIN-00234111 Renewal 11/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.39(c)(2)Chief Executive Officer (CEO) #1 did not complete the following annual training topic during the annual training year, dated 1/1/22 through 12/31/22: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.In-service documentation shows that Cindy Vogan CEO completed training in the Prevention, Detection and Reporting of Abuse, Suspected Abuse, and alleged Abuse in accordance with the Older Adult Protective Services Act and Adult Protective Services Act and applicable protective services regulations on March 10, 2023. This training is offered every year in March and at anytime on myodp.org. We have been unable to locate the documentation of the training for Cindy Vogan, CEO that would have been completed in March of 2022. 11/21/2023 Implemented
2380.39(c)(4)Chief Executive Officer (CEO) #1 did not complete the following annual training topic during the annual training year, dated 1/1/22 through 12/31/22: Recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.In-service documentation shows that Cindy Vogan CEO completed training on Recognizing and Reporting Incidents on March 10, 2023. This training is offered every year in March, and at anytime on myodp.org. We have been unable to locate the documentation of the training for Cindy Vogan, CEO that would have been completed in March of 2022. 11/22/2023 Implemented
SIN-00125758 Renewal 12/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)The two most recent physical examinations for Individual #1 were completed 6/14/16 and 7/7/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.For Individual #1 and all individuals, we will continue to send written reminders of due date for annual physical to families/caregivers 60 days prior to required date of completion. Written reminder will be amended to include the following statement, Please schedule necessary appointment and return Verification (page 2) of scheduled appointment within 10 days of receipt of this notice. Families will now have a form to record date/time of physical and return to verify that appointment has been scheduled. Program Director/Program Specialist will follow up with a phone call 30-40 days before physical is due if written verification has not been received. Assistance of SC will be requested if above listed efforts are unsuccessful. 12/15/2017 Implemented
2380.111(c)(5)The two most recent Tuberculin skin testings for Individual #1 were completed 6/12/15 and 7/7/17.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.For Individual 1 and all individuals on CPS roster, we will continue with the practice of sending written reminders of the need to have the Tuberculin skin testing completed by the required date. The content of written reminder has been amended to include the following statement: Please schedule necessary appointment and return Verification (Page 2) within 10 days of receipt of this notice. Attached to the written reminder is now a form for families/caregivers to record the date/time of scheduled appointment. This form is to be returned in order to verify the fact that the appointment has been scheduled. In the absence of a completed and returned form, Program Director/Program Specialist will place a follow up phone call to families 30-40 days prior to date Tuberculin skin testing is due to be completed. Should the steps listed fail to result in a scheduled appointment, we will solicit the assistance of assigned SC. 12/15/2017 Implemented
SIN-00215368 Renewal 11/22/2022 Compliant - Finalized
SIN-00197323 Renewal 12/10/2021 Compliant - Finalized
SIN-00165527 Renewal 11/08/2019 Compliant - Finalized
SIN-00145988 Renewal 11/30/2018 Compliant - Finalized
SIN-00108424 Renewal 12/16/2016 Compliant - Finalized
SIN-00086466 Renewal 11/13/2015 Compliant - Finalized
SIN-00083015 Initial review 08/20/2015 Compliant - Finalized