Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00223357 Renewal 04/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.48(b)(4)Therapeutic Activity Aide #3's, date-of-hire is 9/6/22, did not receive training in recognizing and reporting incidents. Therapeutic Activity Aide #4's date-of-hire is 8/22/22, did not receive training in recognizing and reporting incidents.The orientation must encompass the following areas: Recognizing and reporting incident.Therapeutic activity aide #3 completed recognizing and reporting incident on 1/23/2023. Therapeutic activity aide #4 completed recognizing and reporting incidents on 1/23/2023. Provider has corrected 2390.48 (b) (4) by adding recognizing and reporting incidents to there orientation program on 9/9/2022. All orientees have completed recognizing and reporting incidents from that date to current.. 09/09/2022 Implemented
2390.49(c)(4)CEO #1's annual training for calendar year 2022 did not include recognizing and reporting incidents. Therapeutic Activity Aide #2's annual training for calendar year did not include recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.CEO #1 has completed recognizing and reporting incidents on 1/11/2023. Therapeutic activity aide #2 completed recognizing and reporting incidents on 1/29/2023. Provider has corrected 2390.49 (c) (4) by adding recognizing and reporting incidents to there annual training program as of January 1, 2023. All current staff have received 2390.49 (c) (4), recognizing and reporting incidents, as part of there current annual training. this training takes place every January. 01/01/2023 Implemented
SIN-00204969 Renewal 05/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(c)(3)Program Specialist #1, date of hire 07/27/20, has not attained an associate's degree or completed a 2-year program from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field.A program specialist shall have one of the following groups of qualifications: (3) Possess an associate's degree or completion of a 2-year program from an accredited college or university in Special Education, Psychology, Public Health, Rehabilitation, Social Work, Speech Pathology, Audiology, Occupational Therapy, Therapeutic Recreation or other human services field; and 3 years experience working directly with disabled persons.Program Specialist #1 has been reassigned a caseload in the 2380 licensed area where he is qualified. This was effective on 5/16/22. The Human resource Director has been notified of this regulation and its requirements. A qualified program Specialist has been assigned to the caseload that Program Specialist #1 formerly was assigned in 2390. 05/25/2022 Implemented
SIN-00166551 Renewal 11/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1 had an assessment completed on 08/16/18 and then an annual assessment completed again on 09/06/19.Each client 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.The program Specialist will be retrained on regulation 151(a) in chapter 2390 of PA Code 55. The Director will conduct a retraining encompassing all assessment issues. Moving forward, it is important for the Program Specialist to have an accurate monitoring system for time sensitive aspects of the job. Utilizing calendars to mark time frames for assessments and ISP's will be required. [Immediately, the CEO or Designee and the program specialist shall develop and implement a tracking system to ensure assessments are completed and provided to plan team members, timely. At least quarterly for 1 year, the CEO or designee shall audit the tracking system and a 10% sample of individuals' current assessments and correspondence documentation showing the program specialist provide all individuals' current assessments to the plan team members, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 11/26/19)] 11/26/2019 Implemented
2390.151(f)The program specialist provided Individual #1's assessment, completed 09/06/19 to the Supports Coordinator and plan team members on 09/09/19 for Individual #1's ISP meeting on 09/26/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.The Program Specialist will be retrained on regulation 151(f) in chapter 2390 of 55 PA Code. The Director will conduct a review of 151(f) and any other items necessary for the retrain. Moving forward, the time management of the Program Specialist case load will be addressed for efficiency. Also, the importance of the ISP team receiving the assessment 30 days prior to the ISP annual meeting will be stressed upon. 11/26/2019 Implemented
SIN-00145694 Renewal 11/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The facility had a fire safety inspection by a fire safety expert on 2/2/18; documentation of the previous fire safety inspection was not available; therefore, compliance could not be measured.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.Moving forward, MCAR will have the Community Participation Supports Director notify the local fire chief by mail that an inspection of our facilities is required by January 31. This letter will be sent on January 2 of each year. The director will follow up in 3 business days to schedule this inspection. [Community Participation Supports Director will be on site to ensure the inspection is completed, timely. Community Participation Supports Director has developed a tracking system to ensure timely completion of annual fire safety inspection and documentation of the inspection shall be kept and available for review by the Department upon requested. (DPOC by AES,HSLS on 12/7/18)] 12/17/2018 Implemented
SIN-00125756 Renewal 12/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(8)The physical examination for Individual #1, completed on 8/28/17, did not include physical limitations of the individual. This section was blank.The physical examination shall include: Physical limitations of the individual.The PCP of individual #1 was contacted by the program specialist and the PCP updated the physical limitations line on 12-15-17. Proof will be sent by email with an attachment. The physical reminder letter that goes out to families/caregiver has also been updated. This also will be sent by email with an attachment. Day Program Director will check 25% of ATF individual¿s physicals on a quarterly basis to ensure the appropriate lines are filled out and documentation will be kept. [Immediately and continuing at least quarterly, a designee shall audit all individuals' current physical examinations to ensure all required information is included and there are not sections of required information left blank. Missing information shall be immediately obtained. Documentation of audits shall be kept. On 12/20/17, day program director provided a directive on the updated aforementioned letter. (AS 12/20/17)] 12/15/2017 Implemented
2380.173(1)(ii)The record for Individual #3 did not include identifying marks.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 #3 Individual data sheet on Therap has been updated to show identifying marks. The form we use states ¿characteristics. Proof will be sent by email with an attachment. Day Program Director will check 25% of ATF individual¿s data pages on Therap on a quarterly basis to ensure the appropriate lines are filled out and documentation will be kept. Program Specialists have been given a directive to ensure all the appropriate lines have been filled out. This will also be sent by email as an attachment. [Immediately and continuing at least quarterly, a designee shall audit all individuals' records to ensure all personal information is included. Missing information shall be immediately completed. Documentation of audits shall be kept. On 12/20/17, day program director provided the aforementioned directive. (AS 12/20/17)] 12/18/2017 Implemented
2380.186(b)The ISP review for review period 8/21/17 through 11/21/17 completed for Individual #2 was not signed and dated by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Individual #2 has signed her ISP Review documentation form on 12-6-17. This will be sent by email with an attachment. Day Program Director will check 25% of ATF individual's ISP Review Documentation Form on a quarterly basis to ensure it is signed by the individual and program specialist and documentation will be kept. Program Specialist have been given a directive to ensure ISP review documentation forms are signed. [Immediately and continuing at least quarterly, a designee shall audit all individuals' most recent ISP review to ensure the program specialist and individual signed and dated the ISP upon review. Documentation of audits shall be kept. On 12/20/17, day program director provided the aforementioned directive. (AS 12/20/17)] 12/06/2017 Implemented
SIN-00105230 Renewal 12/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The hot water temperature in the men's bathroom in the hallway lobby measured 124.5°F at 10:45AM.Hot water temperatures in areas accessible to individuals may not exceed 120°F.On a monthly basis, day program director will test water temperature in all ATF restrooms. An X-Tech thermometer has been ordered and received. All information will be documented on a physical check site form. If the water temperature exceeds 120 degrees, a work order will be emailed to maintenance department that same day. A check of the water temperature was completed on 1-12-17.This system has been put in place to make sure that the same violation will not occur again. All four restrooms were checked. Girls restroom by cafeteria 119F, Mens restroom by cafeteria 120.2 F, Girls restroom in the back ATF area 100.7 F and Mens restroom in the back of ATF 100.9 F. Documentation will be attached and sent by email. This system has been put in place to ensure the same violation will not occur again. Day Program Director has reviewed this regulation. 01/22/2017 Implemented
2380.111(c)(5)Individual #1's Tuberculin skin testing was completed 7/5/14 and then again 7/30/16. 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.Each quarter, 25% of individual¿s files will be checked to assure timelines have been met and notification has been sent out to the family or appointment set up by our residential program. If an appointment is not scheduled, an email will be sent to confirm the date. Program Specialists have been trained to put reminders in their outlook calendars so timelines are met. Day Program Director did a check of eleven files and completed the check on 1-17-17. Day Program Director compared dates of Tuberculin skin test to the outlook calendar to assure reminders are set to send out to families or to set up appointment. All eleven files had reminders set. An email will be sent with an attachment of proof the reminder is set or documentation to show that the reminder has gone out. ( please not this was a random file check and the majority of TB shot reminders go out in the future ). This system has been put in place to make sure that the same violation will not occur again. 01/22/2017 Implemented
2380.181(a)Individual #2, date of admission 3/28/16 had an initial assessment completed 7/20/16.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.On the first day of attendance of a new admission, program specialist will be required to input a notice in their outlook calendar as a reminder to complete the assessment within 60 calendar days after admission. The Day Program Director will check and document all new admissions to ensure that that they are completed within the 60 day window. Since the inspection that was held on 12-9-16, we had one new admission that began on 12-19-16. The individual had their initial assessment completed on 1-13-17. This is documented on the form created by the day program director and will be sent as an attachment by email for review. There will also be a outlook calendar print out showing it was placed on the calendar to check. This system has been put in place to make sure that the same violation will not occur again. 01/22/2017 Implemented
2380.181(f)The program specialist did not provide Individual #3's assessment completed 3/1/16 to the all plan team members including behavior specialist or residential provider.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).Day program director developed a memo on 1-5-17 that has been reviewed at our weekly meeting as well as sent to all program specialists that is its mandatory to send the assessment to the SC or Plan Lead. The Day Program Director will check 25% of individual files each quarter to ensure they are being sent as marked off on the form of who it was sent to. Day Program director did a file check on 11 files and completed on 1-17-17. All eleven files that were checked met the timelines and sent to all team members listed. Again, check was completed by Day Program Director and will be emailed as an attachment to show proof of the check. This system has been put in place to make sure that the same violation will not occur again. [Immediately, the program specialist will provide Individual #3's assessment dated 3/1/16 to the excluded team members and maintain correspondence documentation. The Day Program Director shall review to ensure the program specialist provide all plan team members the individual's assessments as required. Immediately, the program specialist(s) shall be educated by the Day program director that all plan team members shall be provided the individuals' assessment and the agencies policies and procedures to ensure timely completion and maintaining correspondence documentation. (AS 1/20/17)] 01/22/2017 Implemented
2380.186(d)The program specialist did not provide Individual #1's 3 month review ending 7/21/16 and Individual #4's 3 month review ending 8/3/16 to all the plan team members including the residential provider. 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.Day Program Director has made the change to this violation. Program Specialist will be required to check against the declination form to ensure that all parties receive documentation that have requested it. The Program Specialist must send to the SC or Plan lead. Day Program Director will check 25% of total individuals files each quarter to ensure all parties are receiving as compared to the declination form and the information and this will be documented. Eleven files were checked and completed on 1-17-17 . One of the eleven files had one missing person that checked yes on the declination form, but PS did not send to that person. The PS was directed by the day program director that same day to send a copy of the review to the person on the team who requested it. Please review the paperwork that will be attached and sent by email showing that the PS sent out the review that same day. This system has been put in place to make sure that the same violation will not occur again.[Immediately, the program specialist shall provide Individual #1's three month review ending in 7/21/16 and Individual #4's 3 month review ending in 8/3/16 to the excluded team members and maintain documentation of the correspondence. The Day program Director will review this correspondence documentation. Prior to the program specialist providing ISP review documentation to all individuals' plan team member, the program specialist shall review the option to decline documentation, the ISPs and invitation letters to ensure all plan team members are included as required and correspondence documentation is maintained. At least quarterly, for 1 year the Day Program Director, will review the correspondence documentation as well as complete the aforementioned reviews to ensure all team members are provided the ISP reviews for all individuals as required. (AS 1/20/17)] 01/22/2017 Implemented
SIN-00087007 Renewal 11/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62The telephone number of the nearest ambulance was not posted on or by the telephones in Program Rooms 1, 2, 3 and 4.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.The licensing inspector will be sent a copy of the updated phone numbers via email. This was updated by the Day Program Director on 12-9-15 and has been replaced in all areas where there is a phone. Specifically we had left out " Ambulance" on the phone list and this was added in. [The Day Program Director will add monitoring of required telephone numbers to monthly facility checks and ensure a designee completes the checklist and review the checklist for accuracy and completion and address as needed. (AS 12/22/15)] 12/13/2015 Implemented
2380.111(a)The two most recent physical examinations for Individual #3 were completed on 3/24/14 and 4/10/15.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The licensing inspector will be emailed documentation to support how we are going to stay in compliance with this violation. A letter will be sent to each family explaining the importance on having physicals turned in on time. The Program Specialists will continue as we already do sending out physical reminders prior the the physical date to help the families/caregivers remember to set up their physicals. This letter has been written and signed off by the Day Program Director and CEO of MCAR. Program Specialists have also been give a copy of the letter that is being sent to the families /caregivers. This letter will be sent out to the families the week of 12/14/15. [Program specialists will utilize the outlook calendar tracking system and notify the individuals at least 2 months prior to the due date of the physical examinations and work with individuals inaccordance with agency policies and procedures to meet required timeframes. (AS 12/22/15)] 12/13/2015 Implemented
2380.173(1)(iv)The records for Individuals #1 and #2 did not include religious affilation.Each individual's record must include the following information: Personal information including: Religious affiliation.Individual #1 and #2 now have the correct information noted. Proof of this document will be sent via email to the licensing inspector. That specific change has been made. This change was completed by the Program Specialist and is complete. To ensure this will continue to be implemented the Program Specialist will complete the data page on the first day of admission to ensure the documentation is noted. Day Program Director will re-train Program Specialist to make sure it is understood. [Program Specialists will immediately review all individual records to ensure all personal information including religious affiliation is accurate and completed. Day Program Director will review a 25% sample of Individuals' records at least quarterly for the next year to ensure all personal information is completed and accurate. In addition, the Day Program Director will review the next 3 newly admitted individuals' records to ensure personal information is accurate and completed by the program specialists. Documentation of the reviews will be kept.(AS 12/22/15)] 12/13/2015 Implemented
SIN-00067098 Renewal 12/05/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)The primary exit was used on all drills conducted from 12/13 through 11/14.Alternate exit routes shall be used during fire drills.A fire drill was held on 12-12-14 and the secondary exit was used. This was the south exit being used. The person who conducts the fire drills ( Jimmy O'Rourke, assistant director) will use the wooden fire blocker ( a picture of this will be emailed to the inspector) to simulate a real fire to show how to use an alternative exit. The person conducting the fire drill will also review the fire drill log each month to ensure that the primary and secondary exits are being used. The inspector will also recieve copies of the papers from the fire drills helds on 12-12-14. 12/12/2014 Implemented
2380.111(c)(4)Vision and hearing screening was blank on the physical examination for Individual #1 dated 8/22/14.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The physician was contacted on the blank spots on the physical which he filled out and sent back to us.The updated physcial will be emailed to the inspector. In the future, once we recieve a phsyical, the program specialist will review for any missing information. If missing information is found, the doctor will be contacted to see if we can obtain the information. The Program Specialist will document any attempts to get ahold of the doctor. This was completed on 12-12-14. 12/12/2014 Implemented
2380.186(c)(1)A three month review for the period of 9/28/13 to 12/28/13 was not completed for Individual #2.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.An ISP review was not completed for the time period of 9-28-13 to 12-28-13 due to the past Program Specialist not completing the review and that person no longer works here. A quarterly review has been generated for that time period to show what the individual had worked on. This quarterly review will be emailed to the inspector. In order to make sure that a quarterly review is not missed, all Program Specialists will list all review dates in their outlook calendars. Then, if someone no longer works at the agency, the supervisor who oversees that manager can review their outlook calendar so the review is not missed. This will be put in place effective 12-29-14. All program specialists will review their caseloads to ensure reviews are placed on their calendars so it will not occur again. 12/29/2014 Implemented
SIN-00056579 Renewal 11/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)There was no fire drill conducted in the month of June of 2013.(a)  An unannounced fire drill shall be held at least once a month.Day Program Director, Nicci Jones will send in recent fire drills after the date of June 2013. Nicci Jones, Day Program Director has re-trained the Pre-Vocational Director, Jimmy O'Rourke on what is expected for monthly fire drills ( he runs the drills). Jimmy has set reminders in his outlook calendar for different days and times to alert himself to conduct monthly fire drills. [The facility will hold one additional fire drill in addition to the monthly required fire drills within the next three months. The Director will monitor the fire drill log monthly to ensure that all regulatory are met. (CHG 12/2/13)] 11/22/2013 Implemented
SIN-00242497 Renewal 04/04/2024 Compliant - Finalized
SIN-00187784 Renewal 05/20/2021 Compliant - Finalized
SIN-00063349 Change in Location Capacity 04/21/2014 Compliant - Finalized
SIN-00050425 Renewal 11/18/2013 Compliant - Finalized