Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242016 Renewal 05/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Individual #1's Client Rights were most recently reviewed with the individual on 08/24/2023 and 05/31/2022, more than 365 days apart. The review of Client Rights did not occur with Individual #1 annually as required.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Individual rights are to be reviewed at each individual's ISP review meeting. There was a lapse in the time time frame for Individual #1 due to program specialist negligence. The individual in the program specialist role at the time of the error has been moved to a different role in the agency. The lead program specialist has taken over this caseload and is reviewing individual files to ensure that everything is completed correctly. 05/31/2024 Implemented
2390.151(f)There was no documentation showing that Individual #2's 06/02/2023 Individual Assessment was provided to individual plan team members at least 30 calendar days prior to the individual plan meeting occurring on 09/11/2023. The letter sent along with Individual #3's 07/03/2023 Individual Assessment showed that the assessment was not sent to all identified members of the individual's Individual Plan team. The CC line of the letter did not include a representative from Individual #3's residential provider agency.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Individual rights are to be reviewed at each individual's ISP review meeting. There was a lapse in the time time frame for Individual #1 due to program specialist negligence. The individual in the program specialist role at the time of the error has been moved to a different role in the agency. The lead program specialist has taken over this caseload and is reviewing individual files to ensure that everything is completed correctly. 05/31/2024 Implemented
SIN-00222287 Renewal 05/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61At the time of the inspection the kitchen area had a sink. The hot water knob on the kitchen sink was not in good repair. The knob turned to both the left and right to allow water to turn on. However, to get the water to turn off it was not a simple task. You had to continue to play with the knob until the water stopped. This is not in good repair. The left side of the sink was also covered in a cardboard box with duct tape. it was said that the sink was in working condition however that side was covered for an unknown reason. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The hot water knob on the faucet was repaired on 5/15/23. 05/26/2023 Implemented
2390.62At the time of inspection, the ladies bathroom had a soap dispenser on the wall near the bathroom sink. On the wall under the soap dispenser was what appeared to be soap scum from remanence of excess soap. The doorway also had what appeared to be rust around the edge of the door frame.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.The built up soap scum was removed on 5/15/23. The rust from the doorframe will be removed and the frame will be painted. 05/15/2023 Implemented
SIN-00154794 Renewal 04/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(b)-1The fire alarm was not checked during the months of June and July 2018.An employe trained in the operation of the equipment shall check the fire alarm monthly. A section was added to the program specialist's monthly board report to verify that it is completed monthly. 05/28/2019 Implemented
2390.83(b)There was not a written record to indicate that that the fire alarm was checked during the months of June and July 2018.A written record shall be kept showing the date checked, the name of the person checking the alarm and whether or not the alarm was operative.A section was added to the program specialist's monthly board report to verify that it is completed monthly. 05/28/2019 Implemented
SIN-00132444 Renewal 04/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)Individual #1 did not have a three month review for October 2017. 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 Plan of Correction for Violation # 156 (a). The Program Specialist received retraining from Colleen Curtin, Program Manager regarding 156 (a) from the Chapter 2390 regulations on May 16, 2018. The Program Specialist shall complete an ISP review of the services and expected outcomes in the ISP every three months with individual. Colleen Curtin Program Manager will monitor three months reviews on a monthly basis beginning May 16, 2018. 05/16/2018 Implemented
SIN-00111925 Renewal 05/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1 had an assessment done on 2/10/2016. Her assessment for 2017 was also dated 2/10/2016 and contained identical information. There were no updates on progress in any areas such as Vocational Skills, Communication Skills, and Personal Adjustment.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 Manager will provide retraining to the Program Specialist regarding completing assessments during the required time frame in accordance with PA 2390.151 (a). The training will also include updating personal, Vocational and Medical & Safety Information when completing an assessment. ((assessment was updated on 6/1/17 -CH 6/22/2017)) 06/14/2017 Implemented
2390.156(a)Individual #1 had ISP Reviews on 8/16/16, 11/9/16, 2/27/17, and 5/25/17. The time frame between 11/9/16-2/25/17 exceeds the 3 month requirement. Individual #2 had ISP Reviews on 6/7/16, 9/8/16, 1/4/17, and 4/17/17. The time frame between 9/8/16-1/4/17 exceeds the 3 month requirement. Individual #3 had ISP Reviews on 7/13/16, 9/9/16, 12/14/16, and 3/30/17. The time frame between 12/14/16-3/30/17 exceeds the 3 month requirement. Individual #4 had ISP Reviews on 7/7/16, 10/7/16, 2/3/17, 4/13/17. The time frame between 10/7/16-2/3/17 exceeds the 3 month requirement. 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.Meetings with the Individual, the Supports Coordiantor and Avenues Staff are completed quarterly to review the ISP services and outcomes. The Program Specialist will meet with the individual every three months to review the ISP services and outcomes. The Individual and the Program Specialist will sign and date the quarterly report after the quarterly report has been reviewed with the individual every three months regardless of the quarterly meeting date. The program manager will provide re training to the Program Specialist regarding ISP reviews every three months. 06/14/2017 Implemented
SIN-00097252 Renewal 08/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.112(a)Individuals are not being oriented to the program upon their admission. Individual 1 was admitted to the program on 2/8/2016 and was oriented to the program on 4/11/2016 (2 months late). Individual 2 was admitted to the program on 9/28/2015 and received orientation on 11/4/2015 (6 weeks late). Individual 3 was admitted to the program on 3/26/2015, but did not receive an orientation. Upon admission, a client shall be oriented to the facility and to the services offered. Prior to and upon admission, the individual is given a tour of the facility and the handbook is reviewed with the individual by the Program Specialist. The services offered are outlined in the Handbook. After the services outlined in the Handbook have been reviewed with the individual, the individual signs a statement on the release form that states the handbook has been received and reviewed with the individual. In addition to the release form, the Pre Vocational Admission Check List that indicates the Handbook review has been completed and signed by the program specialsit will be filed in the individuals 20 day review section of the file. 09/01/2016 Implemented
SIN-00206724 Renewal 05/18/2022 Compliant - Finalized
SIN-00205305 Renewal 05/18/2022 Compliant - Finalized
SIN-00078358 Initial review 05/07/2015 Compliant - Finalized