Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250452 Renewal 08/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(6)Individual #1's physical examination, dated 9/29/2023, states "not free of communicable disease" but does not indicate the communicable disease or list precautions to be taken to prevent spread of the disease to other individuals.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.Individual #1's physical examination, dated 9/29/2023, states "not free of communicable disease" but does not indicate the communicable disease or list precautions to be taken to prevent spread of the disease to other individuals. Program specialist will have the doctor review and provide a statement that the individual #1 is free of communicable disease. In addition, ATF program specialists were in-services on 9/04/2024 on making sure that they review the physical for accuracy upon completion and prior to attendance to each individual into the ATF. this process will be monitored by the ATF program Specialist Manager each time there is a new admission to the ATF to prevent similar future incidents. 09/04/2024 Implemented
SIN-00230727 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(6)Individual #1's assessment completed 6/20/2023 states the individual will attempt to ingest inedible items and is unable to distinguish between poisonous and non-poisonous substances. Individual #1's individual support plan, last updated 9/01/2023, states the individual would not ingest a poisonous substance.The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.On 09/13/2023, the individual #1¿s assessment was updated to reflect his ISP. The update states that Individual#1 is safely able to use or avoid poisonous materials when in the presence of poisonous materials and that he is not at risk. An in-service was issued to Program Specialist on 09/18/2023 that covered all information in the following areas: (1) the individual¿s ability to safely use or avoid poisonous materials; (2) the individual¿s ability to respond to fire safety and ability level; (3) that the individual¿s assessed abilities and skill level must match the ISP. The Program Specialist was also trained that if it is discovered that the ISP is incorrect, he/she must communicate with the SC and Team via email with the necessary changes at least annually or any time there is a change in the individual¿s needs or skill level. This process will be implemented by the Program Specialist annually and each time there is a new admission. The Program Specialist Manager will monitor this process each time there is a new admission and once a year to ensure compliance and prevent future similar incidents from reoccurring. 09/22/2023 Implemented
2380.182(c)Individual #1's individual support plan, last updated 9/01/2023, states the individual is independent in recognizing the fire alarm, responding to it, recognizing alternative exits and meeting place, and is independent in evacuating. Individual #1's assessment completed 6/20/2023 states the individual can evacuate with minimal support and verbal cues.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 09/13/2023, Program Specialist manger contacted the individual#1¿s Support Coordinator to request needed changes in individual#1¿s ISP to reflect that individual#1 requires verbal cues to recognize a fire alarm, respond to it, recognize exits, and locate an evacuation meeting place. An in-service was given to the Program Specialist 9/18/2023 on making sure that the ISP and the assessment are both accurate and reflect the individual¿s needs. This process will be implemented by the Program Specialist annually and each time there is a new admission or when an individual¿s needs are changed. The Program Specialist Manager will monitor this process each time there is a new admission and once a year to ensure compliance and to prevent future similar incidents from reoccurring. 09/22/2023 Implemented
SIN-00158176 Renewal 06/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.172(b)Individual #1's ISP review, for review period 12/1/18 to 2/28/19, had the review period edited; however the person making the entry did not sign or date the edit. Individual #1's ISP review, for review period 3/1/19 to 5/31/19, had the review period edited; however the person making the entry did not sign or date the edit.Entries in an individual¿s record shall be legible, dated and signed by the person making the entry.Individual #1's ISP review, for review period 12/1/18 to 2/28/19, and for review period 3/1/19 to 5/31/19 had the entry corrected. The Program Specialist who edited the review date has added her initial and dated the same day, July 5th, 2019. Also, the facility initiated an in-service to all Program Specialists on making sure when making any entry into an individual¿s chart, or correcting errors, they must put a single line through, then initial and date. This in-service will be completed by July 25, 2019. In addition, Program specialist Managers will be monitoring this process when doing chart review quarterly to ensure the implementation and prevent future similar deficiencies from reoccurring. 07/09/2019 Implemented
SIN-00211132 Renewal 09/13/2022 Compliant - Finalized
SIN-00193985 Renewal 10/14/2021 Compliant - Finalized
SIN-00179063 Renewal 11/10/2020 Compliant - Finalized
SIN-00138269 Renewal 07/11/2018 Compliant - Finalized
SIN-00118307 Renewal 07/31/2017 Compliant - Finalized