Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00246569 Renewal 06/20/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 provided a negative TB test on 3.25.22 and not again until 4.12.24. This exceeds the 2 year requirement.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.The Provider has reviewed with the Program Specialist immediately after the inspection to properly review the dates of all TB test for individuals. Also, a change to the Physical Form was made to provide the PCP with the opportunity to determine if it is medically necessary to obtain a TB test every other year. 06/24/2024 Implemented
SIN-00169149 Renewal 01/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)The section pertaining to health history was left blank on Individual #1's physical form.The physical examination shall include: A review of previous medical history.Individual #1 physical was returned to the family to complete all missing sections. And families were notified that when attending the annual physical to ensure all sections are properly completed. As an agency we will begin to highlight all sections within the physical to assist in ensuring the physical is completed. . 02/28/2020 Implemented
2380.111(c)(4)The section pertaining to hearing and vision was left blank on Individual #2's physical form and was not addressed elsewhere.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #2 physical was returned to the family to complete all missing sections. And families were notified that when attending annual physical to ensure all sections are properly completed. As an agency we will begin to highlight all sections within the physical. 02/28/2020 Implemented
2380.111(c)(7)The section pertaining to health maintenance needs was left blank on Individual #1's physical form and they were not addressed elsewhere.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Individual #1 physical was returned to the family to complete all missing sections. All families and caregivers were notified that when attending annual physical to ensure all sections are properly completed. As an agency we will begin to highlight all sections within the physical. 02/28/2020 Implemented
2380.111(c)(8)The section pertaining to physical limitations was left blank on Individual #1's and Individual #2's physical forms.The physical examination shall include: Physical limitations of the individual.Individual #1 physical was returned to the family to complete all missing sections. And families were notified that when attending annual physical to ensure all sections are properly completed. As an agency we will begin to highlight all sections within the physical. 02/28/2020 Implemented
2380.111(c)(10)The section pertaining to information and treatment pertinent to diagnosis and treatment in case of emergency was left blank on Individual #1's and Individual #2's physical forms.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.This physical was returned to the family to have it completed while they are making the other corrections on the physical form that pertain to the other citations. All families and caregivers where notified to ensure that while attending annual physical to ensure all sections are completed. As an agency we are going to highlight all pertinent section. 02/28/2020 Implemented
2380.111(c)(11)The section pertaining to diet was left blank on Individual #2's physical form and not addressed elsewhere.The physical examination shall include: Special instructions for an individual's diet.The physical was returned to the individual caregiver to have the section pertaining to diet completed. All familes were notified while attending annual physicals. As an organization we are going to highlight the sections to ensure that they are properly completed. 02/28/2020 Implemented
SIN-00147567 Renewal 01/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 and Individual #2 both had late physical exams. Individual #1 had a physical exam on 4/3/2017 and not again until 6/12/20018. Individual #2 had a physical exam on 3/7/2017 and not again until 5/17/2018. Repeat violation: 2/8/2018.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Day Programs at Cares have created a Physical Review team to work together to ensure that annual physicals for Vip's are completed in the required timeframe. We have also set up that we start sending reminder letters to families and three months in advance. The review team consists of Program Specialists from other centers within the agency to review the physicals and TB tests. 01/12/2019 Implemented
2380.113(a)Staff #1 had a physical exam on 10/14/2015. He didn't have another physical exam until 1/15/2018, which exceeds the b-annual requirement.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.The Day Programs at Cares have created a Physical Review team to work together to ensure that physicals for staff are completed in the required timeframe. We have also set up that we start sending reminder letters to staff three months in advance. This is to ensure that they are notified in enough time to ensure that they obtain the required physical 01/12/2019 Implemented
2380.113(c)(2)Staff #1 had a TB test on 10/14/2015. He didn't have another TB test until 1/22/2018, which exceeds the requirement.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.The Day Programs at Cares have created a Physical Review team to work together to ensure that annual physicals and Tb tests for staff are completed in the required timeframe. We have also set up that we send reminder letters to staff three months in advance. This ensures that they have enough time to get the physical completed in a timely manner. 01/12/2019 Implemented
SIN-00127900 Renewal 02/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's annual physical is late. One was completed on 01-24-17 and another is not scheduled to occur until 02/16/18.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.As an agency we have established a tracking sheet to ensure that the requirements are being upheld. The tracking form was completed the date of the inspection 02/08/2018 Implemented
2380.111(c)(3)Individual #1's last TDaP was on 06/06/07. Another one was due by 06/06/17.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.As an agency we have informed all families, providers of the importance of the TDaP. All parties have been informed that annual physicals must be completed with all required documents. 02/09/2018 Implemented
2380.111(c)(5)Individual #1 has a late TB test. She had one 05-11-15 and did not have another until 08-14-17.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.As an agency we have created a spreadsheet that shows when all individuals are due for their TB tests. The spreadsheet will be utilized to present the families/providers of upcoming TB tests 02/09/2018 Implemented
2380.111(c)(10)Information pertinent to diagnosis and treatment in case of an emergency was not on the physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.We have instructed all consumers that CARES physical forms are required to be completed for the annual physical. We will only accept other physical forms if the form has all of the required licensing information on them. (( All individual physicals will be updated to contain all required information -CH 5/8/18)) 02/08/2018 Implemented
SIN-00108289 Renewal 03/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)Exits utilized were not documented on fire drill held on 10/5/16 and 12/6/16. The fire drill form does not indicate if the fire alarm system was operable on 9/23/16, 10/5/16, 11/21/16, 12/6/16, 1/9/17, and 2/21/17.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.Program Specialist, Team Lead, and Staff, will all complete review Fire Safety Training. Program Specialist will complete a monthly check of the Fire safety records and initial that they were completed accurately. Team lead will also complete a monthly check of the fire safety records and initial they were completed and accurate. 04/28/2017 Implemented
2380.111(c)(1)This section was not completed on Individual #4's physical.The physical examination shall include: A review of previous medical history.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.111(c)(5)Individual #4 was admitted to program on 7/26/2016. She didn't have a TB test until 11/15/2016.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.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.111(c)(7)This section was not included on the physical exams for individual #1 and individual #4.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.111(c)(8)This section was not completed on Individual #4's physical.The physical examination shall include: Physical limitations of the individual.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.111(c)(9)This section was not completed on Individual #4's physical.The physical examination shall include: Allergies or contraindicated medication.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.111(c)(10)This section was not included on the physical exams for individual #1, individual #3 and individual #4.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.111(c)(11)This section was not completed on Individual #1's and Individual #3's physical.The physical examination shall include: Special instructions for an individual's diet.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.113(c)(3)This section was not completed on staff #1's physical exam dated 9/17/16.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.Human Resources Coordinator, Kate Zimmerman, will include a checklist in the front of each staff's file that documents everything required before they are able to begin/continue work at the day program. This would include the physical and note the sections of the physical that need to be completed. KZ will also include a statement at the top of the physical form that notes that all fields must be completed prior to submission. 04/28/2017 Implemented
2380.173(1)(ii)Race, hair & eye color were not listed in the records for individual #1, individual #2, individual #3, and individual #4. Identifying marks were not listed in the record for individual #4.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.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.173(1)(iii)Language/means of communication was not listed in the records for individual #1, individual #2, individual #3, and individual #4.Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.173(1)(iv)Religious Affiliation was not listed in Individual #4's record.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.181(d)Individual #4's initial assessment was completed on 8/2/2016. The Program Specialist did not sign & date this assessment.The program specialist shall sign and date the assessment.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.186(a)Individual #1 had ISP Reviews on 2/17/16, 5/23/16, 8/23/16, and 11/9/16. The timeframe between 11/9/16-3/20/17 (date of inspection) exceeds the 3 month requirement. Individual #2 had ISP Reviews on 3/26/16, 7/26/16, and 12/15/16. The timeframe between 3/26-7/26/16 and 7/26-12/15/16 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 individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
2380.186(b)Individual #1 didn't sign his ISP Reviews dated 2/17/16 and 8/23/2016.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Program Specialist mentor AD will create a checklist that will be placed in the front of each individuals file. This will be signed by each program specialist during a monthly audit of Assessments, ISP, Quarterly review forms, Facesheet, and Physicals. Program specialists will be verifying forms are completed within the specified timeframes and contain all necessary signatures and information. 04/28/2017 Implemented
SIN-00266139 Renewal 06/18/2025 Compliant - Finalized
SIN-00223692 Renewal 06/26/2023 Compliant - Finalized
SIN-00205387 Renewal 06/23/2022 Compliant - Finalized
SIN-00088011 Initial review 01/07/2016 Compliant - Finalized