Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243693 Renewal 06/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill record completed on 9/24/23 did not include the time the drill was completed as this section was left blank on the form.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.The time of the fire drill was added to the Fire Drill Log. 06/13/2024 Implemented
SIN-00165236 Renewal 11/12/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual # 2 received annual fire safety training late; fire safety training was given on 3/06/18, then not again until 4/17/19.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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, and smoking safety procedures if individuals smoke at the facility.The regulation was reviewed with the Program Specialist at the locations and ensured that they know the requirements for this regulation. I will be reviewing the fire safety trainings with the PS to ensure all annual fire trainings are completed in the required time period. 11/14/2019 Implemented
2380.111(c)(5)Individual #1 did not have Tuberculin skin testing with his current physical examination on 1/23/19. There was no documentation of Tuberculin skin testing in the individual's record.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.Reviewed with the Program Specialist the procedure for TB testing according to regulations. The physical team will continue to review all Physicals on a monthly basis to ensure that this does not occur again in the future. ((Individual #1 had TB testing completed -CH 12/18/2019)) 11/14/2019 Implemented
2380.181(e)(12)The annual assessment completed on 4/05/19 for Individual #2 did not contain recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Reviewed the regulation with the Program Specialist and then ensured that the PS properly knew how to complete the required information in the annual assessment. ((The assessment for Individual #2 was updated with the required information. - 12/18/19 CH )) 11/14/2019 Implemented
SIN-00144664 Renewal 10/31/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #1 was hired on 3/13/2017. He didn't have a PA Criminal check completed until 11/10/2017.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.The HR Department has a tracking system in place now that all employees are not required to start employment at any program until all clearances have been ordered. This individual was employed prior to the employee tracking system in place. 11/02/2018 Implemented
2380.111(a)Individual #1 had a physical exam on 3/29/2017. He didn't have another physical exam until 6/20/2018, which exceeds the annual requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Cares is starting to send letters out to the individuals caregiver 3 months prior to the annual physical date to ensure that the physical is completed in the 12 month period. 11/02/2018 Implemented
2380.111(c)(5)Individual #1 had a TB test on 3/1/2016 & not again until 4/10/2018. Individual #2's most current TB test is dated 4/18/2016. The requirement was exceeded for both individuals.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.Physicals are now required to be on Cares Annual Physical Form, and we are having the Review Team review all physical to ensure that all required dates are met. 11/02/2018 Implemented
2380.111(c)(8)This section was blank on Individual #2's physical exam dated 11/1/2017.The physical examination shall include: Physical limitations of the individual.Cares is requiring all annual physicals to be completed on Cares annual physical form. The review team will ensure that all areas of the annual physical will be completed. 11/02/2018 Implemented
2380.181(f)Individual #1's annual assessment was not sent to his team 30 days prior to his ISP meeting. His ISP meeting was held on 4/26/2018 and his annual assessment was sent to his team on 4/17/2018.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Cares has developed a assessment distribution form to distribute the assessment prior to 30 days to the annual assessment. The Program Specialist has a spread sheet that identifies when the VIP's ISP meeting should be scheduled by so they can work to have the Assessment completed 30 days prior to the annual ISP. 11/02/2018 Implemented
SIN-00127053 Renewal 11/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)There was no written validation in either Individual #1's or Individual #2's file that showed the assessment was sent to the SC and team members at least 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Cares created a document that acknowledges that the SC received the document either via, fax, mail, email, or hand delivered 30 days prior to annual ISP date. And completed document will be kept in the VIP file. 11/16/2017 Implemented
SIN-00266135 Renewal 06/12/2025 Compliant - Finalized
SIN-00223688 Renewal 06/21/2023 Compliant - Finalized
SIN-00205389 Renewal 06/10/2022 Compliant - Finalized
SIN-00105509 Initial review 12/28/2016 Compliant - Finalized