Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00205641 Renewal 05/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Verification was not provided that Individual 3's 7/6/21 assessment was sent to the sister and contingent guardian at least 30 days prior to the 3/22/22 ISP meeting. This ISP states that this person should be invited to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist had invited individual¿s #3 parents (and guardians) to the ISP 30 days prior to the 7/6/21, but did not include the individuals sister. The program specialist informed the sister of the content of the 2021 ISP through the ISP meeting, but not documented invitation. 06/09/2022 Implemented
SIN-00162727 Renewal 09/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Hot water temperature in individual #1's master bathroom sink measured at 129.2 degrees Fahrenheit. This condition can lead to hazardous temperatures for faucets and fixtures and surfaces around the sink. Floors, walls, ceilings and other surfaces shall be free of hazards.The Director of Maintenance evaluated individual #1's master bathroom sink and determined the water temperature was over the allotted temperature of 120 degrees. The Director of Maintenance immediately placed the bathroom sink out of use until the outside contractor could evaluate the situation. The other bathroom in the home was evaluated and it was determined the other areas of the home were in line with the appropriate water temperature. On 10/7/2019, the outside plumbing, heating and cooling service evaluated individual's #1 master bathroom sink, he supplied and installed an under counter mixing valve for the powder room faucet and the temperature was set to under 120 degrees. The third shift direct care staff test the water temperature throughout the home daily on 3rd shift, the House Manager signs off on the water temperatures. The house managers complete their own water temperature checks on a monthly basis or more frequently if needed and documents the temperature on the Community Programs Home Monitoring/Audit Checklist. The House Manager will hand the monthly audit into the residential Coordinator and any items in dis-repair will be forwarded to the maintenance department for correction through the electronic WorxHub maintenance system. The Direction of Operations will complete a quarterly audit of 3 homes per quarter. She will complete the Community Programs Home Monitoring/Audit Checklist for each home and forward to the Director of Community Programs for review. Any items in dis-repair will be forwarded to the maintenance department for correction through the electronic WorxHub maintenance system. The Quality Management team will conduct semi-annual audits of each home. The documentation will be forwarded to the Director of Community programs for review. Any items in dis-repair will be forwarded to the maintenance department for correction through the electronic WorxHub maintenance system. Completion Date: Ongoing, Monthly Parties responsible; House Manager, Residential Coordinator, Director of Operations, Director of Community Programs, Maintenance Department and Quality Management Team. 10/07/2019 Implemented
SIN-00120223 Renewal 08/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)THE WINDOW IN THE HALLWAY BATHROOM DID NOT HAVE A SCREEN AND WAS THE ONLY SOURCE OF VENTILATION FOR THE ROOM SINCE IT DID NOT HAVE AN EXHAUST FAN. Windows, including windows in doors, shall be securely screened when windows or doors are open. A maintenance request for Glen Springs Home- (main bathroom) reporting the window needed a screen was sent to the Facilities Maintenance Director on 8/7/2017. On 8/17/2017 the maintenance team made and installed a new screen to the main bathroom at Glen Springs. Going forward windows and screens were added to be checked by maintenance on the monthly maintenance checklist that is reviewed by the Facilities Maintenance Director. The Facilities Maintenance Director will report any issues of non-compliance or safety to the Director/Administrator of the Program immediately. 08/17/2017 Implemented
6400.112(c)THE FIRE DRILL THAT OCCURRED ON 10/08/2016 DID NOT RECORD THE EVACTUATION TIME. 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 or smoke detector was operative. The fire drill policy was revised om 9/19/2017. All drills will be sent to the new management position (Residential Coordinator of the CLA's) by the 20th of every month to be reviewed to ensure the following documentation is accurate; date, time, the amount of time it took for the evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detectors were operative. The Residential Coordinator will forward the monthly fire drills to the Facilities Maintenance Director who will keep the original documents and forward a copy of the drills to the House Manager of each facility for their fire drill documentation binder at each home and the Quality Management Team who reviews and keeps a master drill list that reviews patterns on a monthly basis and makes recommendations to the Directors and Administrator of the Program. 09/30/2017 Implemented
SIN-00091924 Renewal 04/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.21(b)Staff #5¿s date of hire was 8/10/15 and the FBI check was completed on 3/25/16.The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued.Clearances and Physicals Pre-Hire ¿ FBI, PA Criminal History and PA Child Abuse clearances are completed and must be received prior to any candidate being hired and starting work at DPV or DGV. ¿ Any clearance that is returned with a rap sheet is flagged for a Rap Sheet Review Meeting. The candidate is not hired until a determination is made at the Rap Sheet Review Meeting. o Participants in the Rap Sheet Review Meeting include the HR Director, Administrator, Divisional Executive Director and, if needed, the Department Director. o Candidates convicted of misdemeanors and/or felonies specified as prohibited offences per the Employee Disclosure Statement are not hired. o Rap sheets containing other offences are reviewed and a decision is made to hire or not. Factors taken into consideration include the nature of the offence[s], the number of offences, the length of time since the last offence, the candidate¿s age at the time of the offence[s], the candidate¿s interview, work history and references. ¿ All candidates must have a physical and PPD test [or chest X-Ray as determined by the physician] prior to being hired and starting work at DPV or DGV. ¿ The physical form is reviewed for completeness, including the physician¿s statement that the candidate is free from communicable disease, by the HR Recruiter prior to the candidate¿s start date. ¿ A candidate with a physical or PPD [or Chest X-Ray] result that is questionable is not permitted to begin work until the question is resolved. A final determination is made by the appropriate HR Director. ¿ All documents are kept in the permanent personnel 07/01/2016 Implemented
6400.141(c)(10)Individual #4¿s physical dated 10/14/15 did not document if they were free of communicable disease. The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Individual's #4 physical dated 10/14/2015 was reviewed by their primary physician on 4/13/2016 at 3:56pm and the physician deemed through documentation that individual #4 is free of communicable disease. Going forward, the health care coordinator will review all annual physicals upon completion to ensure all areas of the physical are complete and accurate. The Director of Nursing will complete file audits on annual physicals (8 per quarter to ensure completion). 06/17/2016 Implemented
SIN-00075325 Renewal 03/30/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1 received a physical examination on 2/5/13 and not again until 2/24/15. 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Each Supervisor will be given notice of their direct reports physical dates. Human Resources will generate the notice when it is 60 days prior to the expiration of the previous year. The supervisor of the employee(s) needing a physical will be copied on notices sent to the individuals. This will ensure that the employee is held accountable to obtain in the time frame needed under regulations. If the time frame needed is not met the Employee will be removed from the schedule. (A record review of all staff records will be completed within 30 days of receipt of this plan to identify any other staff records out of compliance with this regulation. The Human Resources director will use a tracking system to ensure the timeliness of staff physical exams. The Human resources director will notify the staff member and their supervisor verbally and in writing of the impending expiration of the physical exam 60 days prior to the expiration. A second notification will be sent to the staff member and supervisor 30 days prior to the expiration of the physical exam. A third notification will be sent to the staff and supervisor 1 week prior to the expiration of the physical exam. The human resource director is responsible to keep track of the notifications on the spreadsheet. All notifications will be kept in the staff member's record. AH 10.29.2015) 11/30/2015 Implemented
SIN-00061590 Renewal 03/13/2014 Compliant - Finalized
SIN-00047486 Renewal 03/01/2013 Compliant - Finalized