Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00277859 Renewal 11/25/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.88(f)Three (3) of the four (4) fire extinguishers located on-site were tagged with a September 2024 inspection date, which exceeds the requirement for annual inspection. The extinguishers were located at the (1) back exit, (2) front exit, and (3) outside the rear kitchen door.Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher.Center director contacted vendor on 12/2/2025 to inspect and replace expired extinguishers. On 12/5/2025 the inspection and replacement was completed by Impact fire. 12/05/2025 Implemented
2380.89(d)The 02/19/25 Fire Drill noted an evacuation time of 3 minutes and 11 seconds, which exceeds the 3-minute extended evacuation time established by the Fire Safety Expert on 02/06/25. The 02/19/25 drill was the only drill on record for the month of February 2025.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Center director was retrained on fire drill procedures and evacuation times. 12/03/2025 Implemented
2380.21(l)The provider did not hold conversations with Individual #1 and Individual #2 relating to their preferred community participation and activities as required by ODP Announcement 24-061.An individual has the right to make choices and accept risks.Provider immediately met with the individuals to discuss their interests in community participation and documented in their quarterly note. This will be continued moving forward for all ODP members. Program Specialist was trained on the above regulation. 12/02/2025 Implemented
2380.126(b)Individual #1 is prescribed Propranolol 10 mg tablet (take ½ tablet by mouth twice daily for hand tremors). At the time of inspection at 11:55 am, the 1:00 pm administration was already removed from the blister packet and initialed as administered on the MAR; however, the Nurse on duty confirmed that the medication had not yet been administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Center director retrained the agency nurse and monitored all medication for the remainder of the day to ensure accuracy and timeliness. A note was placed on 12/2/2025 in the MAR book adressed to ALL nurses reminding them of following the prescribed administration times and adhering to the one hour window when appropriate. 12/02/2025 Implemented
SIN-00259402 Renewal 01/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(d)The first aid kit was missing tweezers and a thermometer.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.The Center Director has added the tweezers and the thermometer to the first aid kit. 01/10/2025 Implemented
2380.89(d)The last letter from a fire safety expert for an extended fire drills was completed on 12/18/23 for drills up to 3 minutes. There was no updated letter in the record for 2024 at the time of the review.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.The Center director received a new letter, on 2/6/25, allowing an extension from 2.5 minutes to 3 minutes to evacuate the building in a safe manner during fire drills. to the time for evacuation during fire drills. 02/06/2025 Implemented
2380.36(b)Staff training records do not have a sign in sheet noting that they were trained by a fire safety expert. On 6/5/24 there is document that states a training was conducted, however, there was no sign in sheet of who participated.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Center director has added the training form to the current annual training letter. 02/18/2025 Implemented
SIN-00217156 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)The letter from the fire safety expert to extend evacuation time for fire drills was outdated and should be within the past year. Last written, 1/13/20.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.The Director contacted the Uwchlan Township Fire Marshal by telephone and by email to request an updated Fire drill letter for Active Day of Exton. An updated letter was received on January 10, 2023. 01/10/2023 Implemented
2380.36(a)Fire safety for Staff #1, Staff #2, Staff #3, Staff #4, Staff #5, expired 4.19.2021. Fire safety and CPR need to be completed every two years.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.CPR for staff #1,2,4,5 (#3 is a repeat) was conducted on 4/19/2021 and expired on 4/19/2023. I believe they read the certificate incorrectly. Staff #1 resigned on 1/20/2023 and staff #4 resigned on 10/13/2021 and no longer require CPR. Staff members #2 and #5 have a new CPR card effective 3/21/2023 and expires 3/2025. The annual fire safety training with a fire safety expert was held on 5.17.2023. The Fire safety experts credential's, letter for inservice and inservice sign in are attached for all current staff at the center. 05/17/2023 Implemented
SIN-00167253 Initial review 12/09/2019 Compliant - Finalized