Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00265939 Renewal 05/12/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)At the time of the inspection, there was a trash can in bathroom #1 that has a pointed metal arm sticking out from the can. A pedal was originally covering it which lifts the lid, but it was pulled off by a participant and now needs to be replaced because without the pedal to cover the metal piece, it becomes a safety hazard.Floors, walls, ceilings and other surfaces shall be free of hazards.1. Upon discovery during the inspection, the metal pedal was reattached immediately to eliminate the hazard. 2. It was also confirmed at the time of the inspection that no individual was harmed due to the hazard. 05/22/2025 Implemented
2380.173(1)(ii)The identifying marks section of Individual #2's personal information form is blank.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.The personal information form was reviewed with Individual #2's parents who entered "None" on the form for identifying marks. 05/22/2025 Implemented
2380.181(a)Individual #1's annual assessment was completed on 10/19/2023 and not again until 11/8/2024, which exveeds the one year and 15-day grace period allowed by this regulation. The initial assessment for Induvial #2 was late by 1 day. Individual #2's start date was 3/12/2025. The assessment was completed 5/12/2025 but should have been done by 5/11/2025.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.1. The initial assessment due within 60 days and then annually thereafter were completed after the required due date. Provider was able to show other assessments that were completed on time. 05/22/2025 Implemented
2380.183(b)At the time of the inspection, the provider did not have a copy of Individual #1's ISP meeting sign in sheet, which documents that at least 3 members of the Individual's plan team were present at the meeting where the Individual's plan was developed and/or revised.At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised.1. The day of the inspection, the CPS Program Specialist sent an email to the Supports Coordinator to request a copy of the ISP Signature Sheet. 05/22/2025 Implemented
2380.183(c)At the time of the inspection, the provider did not have a copy of Individual #1's ISP meeting sign in sheet, which documents the list of individuals who participated in the ISP plan meeting, in Individual #1's file as required by this regulation.The list of persons who participated in the individual plan meeting shall be kept.1. The CPS Program Specialist emailed the Supports Coordinator at the time of the licensing inspection to request a copy of the ISP Signature Sheet for the meeting being reviewed. 05/22/2025 Implemented
SIN-00245664 Renewal 06/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.14(a)The fire code operational permit was last completed on 8/04/2022 and the permit is only valid for one year. This permit expired on 8/4/2023 and there hasn't been one completed since that date in 2022.A facility shall have a valid firesafety occupancy permit listing the appropriate type of occupancy from the Department of Labor and Industry, the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton.UCP's Director of Facilities has reached out to Lower Allen Township to schedule another inspection ASAP 06/07/2024 Implemented
2380.183(3)Induvial #2's ISP meeting was held on 5/28/2024. At the time of the inspection, the provider did not have the list of persons who participated in the individual plan meeting nor was an email sent to the SC requesting a copy of the signature page documentation.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.CPS Supervisor emailed a request to the SC for the ISP meeting signature page the same day of the licensing inspection. 06/07/2024 Implemented
2380.21(u)Individual #1's 2024 rights were late. Rights were signed 2/21/23 and not again until 4/1/24. Individual #2's rights were signed on 2/9/2023 and not again until 5/01/2024, which exceeds the annual with 15-day grace requirement by this regulation.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.CPS supervisor trained on the importance of timeliness in reviewing these documents with each individual. 06/07/2024 Implemented
SIN-00165429 Renewal 10/31/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)The annual assessment for Individual # 2 was completed late. His assessment last year was completed on 7/3/18 and not again until 8/15/19.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The program specialist has created a spreadsheet to track and maintain due dates of assessments to ensure they are being completed within 1 year prior to or 60 calendar days after admission to the facility and then updated annually thereafter. The program specialist will review the tracking spreadsheet on a weekly basis and complete all assessments timely to avoid any of them being late. Additionally, internal quarterly audits will be completed to by trained group of staff using the Adult Training Facility licensing instrument. 11/21/2019 Implemented
2380.181(e)(5)Individual #1's Assessment dated 09/06/19 does not assess her ability to self-medicate. The assessment instead states "Individual does not take any medications at CPS. She does not administer her own medications at home and has not expressed a desire to do so. She is fully reliant on others to prepare medications at the prescribed time".The assessment must include the following information: The individual's ability to self-administer medications.The program specialist is responsible for completing assessments timely. Individual #1's assessment has been updated to include the individuals' specific abilities to self-administer medications. Additional and concentrated regulation trainings have been implemented at monthly staff meetings and will continue as a way to review what is required. These trainings are presented by UCP's Senior Director of Operations. Additionally, internal audits will be completed on a quarterly basis using the Adult Training Facility licensing instrument to make sure all documentation is complete and accurate and that processes are being followed as required by the regulations. 11/21/2019 Implemented
SIN-00224740 Renewal 05/26/2023 Compliant - Finalized
SIN-00201327 Renewal 03/08/2022 Compliant - Finalized
SIN-00180447 Renewal 12/08/2020 Compliant - Finalized
SIN-00141463 Initial review 09/12/2018 Compliant - Finalized