Inspection IDReason for InspectionInspection DateInspection Status 
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