Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00294267 Renewal 08/24/2026 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.67(a)At the time of the 08/25/26 inspection, the sink faucet handle in Staff #7's was rusted and pitted.Furniture and equipment shall be nonhazardous, clean and sturdy.A work order was submitted to the facilities team requesting that the faucet be replaced 09/14/2026 Accepted
2380.72(b)At the time of the 08/25/26 inspection, there was a long crack in the concrete sidewalk to the left of the garage door; a section of the crack is deep enough to be a tripping hazard.The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.Work order was placed to facilities. Day Services Coordinator retrained Program Specialists and Studio Managers on regulation 55 PA Code Chapter 2380.72 (b). The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions 09/15/2026 Accepted
2380.111(c)(8)Individual #4's most recent physical completed on 10/9/25 does not document their physical limitations. One section of the physical says, "see attached." Upon seeing attached, that section is blank.The physical examination shall include: Physical limitations of the individual.8/25 Day Services Coordinator contacted residential team for individual to request completion. 8/27 Studio Manager created an updated physical reminder to send out with physicals 8/27 Day Services Coordinator retrained Program Specialists and Studio Managers on Regulation 55 PA Code Chapter 2380. 111 (c) (8) Physical limitations. 8/28 Physical was returned to the manager of residential home for corrections to be made by the physician and returned to the studio. 09/08/2026 Accepted
2380.111(c)(9)Individual #3's most recent physical completed on 2/10/26 documents the individual has no medication allergies. However, they are allergic to sulfa drugs.The physical examination shall include: Allergies or contraindicated medication.8/25 Studio Manager emailed #3's mother to clarify if individual #3 is still allergic to sulfa drugs 8/27 Studio Manger created an updated physical reminder to send out with physicals.8/28 Day Services Coordinator retrained Program Specialists and Studio managers on regulation 55 PA Code Chapter 2380 111 (c) (9) allergies/Contraindicated Meds. 8/28 Physical returned to mother for corrections to be made by physician. 09/14/2026 Accepted
2380.113(b)Staff #6's physician did not sign and date the most recent physical form completed on 2/18/25, the date of the physical. It was signed and dated later.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.Retraining shall be provided by the Director of Human Services to the HR team on staff requirements 09/15/2026 Accepted
2380.172(a)Conversations regarding CPS preferences are kept on the same document for everyone, as opposed to documenting this in their own records as required.A separate record shall be kept for each individual.8/27/26 Quarterly conversation form created by Studio Manager for each individual. 8/28/26 Day Services Coordinator retrained Program Lead, Program Specialists and Studio Managers on regulation 55 PA Code Chapter 2380 172 (a). A separate record shall be kept for each individual have been completed. 09/30/2026 Accepted
2380.39(c)(5)Neither Staff #5 nor Staff #6 had training on the Use of Positive Behavior Supports in 2025 calendar year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.All Heart Studio staff shall complete training on Positive Behavioral Supports by 9/15/26 09/15/2026 Accepted
2380.183(b)Individual #1 did not have 3 members present in addition to themselves and their designated people at the most recent ISP team meeting held on 3/31/26.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.8/27 Studio Manager sent an email to Individual's #1's Support coordinator requesting to be notified if additional team members are needed to meet requirements of 3 additional members. 8/28 Day Services Coordinator retrained Program Specialists and Studio Managers on regulation 55 PA Code Chapter 2380. 183 (6) (b).. 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 being developed or revised. 09/11/2026 Accepted
SIN-00274154 Renewal 09/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)Individual #1's most recent physical completed 06/12/25 does not document their health maintenance needs and bloodwork regiment. It is documented as N/A.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.9/29/25- Day Services Coordinator updated Day Services Physical form. 10/1/25- Studio Manager sent an email requesting Individual #1 physical corrections. 10/16/2025 Implemented
2380.36(b)Staff #3 completed Fire Safety training on 02/28/24 and not again until 03/25/25, outside of the annual timeframe.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff #3 completed Fire Safety training on 03/25/25 to come back into compliance. An immediate audit of all employee training records is being conducted to verify that all other staff have received Fire Safety training within the required timeframe. Any gaps identified will be corrected promptly. Audit will be completed by Oct. 17, 2025, by Training Associate. 10/17/2025 Implemented
SIN-00254259 Renewal 11/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)At the time of the 11/13/24 inspection, there was excessive amount of dirt in the stand-up shower in the bathroom next to the First Aid room.Clean and sanitary conditions shall be maintained in the facility.On 11/14/24, the Day Services Coordinator sent a maintenance request for leaking showerhead, causing build-up on the floor of the shower. On 11/14/24- the Day Services Coordinator cleaned the shower, removing an excessive amount of dirt. 12/30/2024 Implemented
2380.69(e)At the time of the 11/13/24 inspection, there were no towels in the bathroom attached to the last office on the right in the administration hall located in the south wing.Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.11/14/24- Program Lead placed paper towels in office restroom. 12/30/2024 Implemented
SIN-00235914 Renewal 12/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(10)The annual assessments for individual #1 (dated 9/11/23), individual #2 (dated 9/26/23), and individual #4 (dated 11/21/23) did not contain any information in the lifetime medical history section. This section indicated to "see lifetime medical history attached". At the time of the inspection, there was not a lifetime medical history attached to individual #1, individual #2, or individual #4's assessment.The assessment must include the following information: A lifetime medical history.The Assessment Checklist still be updated to include checking for Lifetime Medical History to be attached to the assessment by 12/22/23. 02/29/2024 Implemented
2380.21(q)The individual rights for individual #1, signed 6/18/23, does not include the right to participate in plan development and implementation of the individual plan.An individual has the right to participate in the development and implementation of the individual plan.12/20/23- Audit of the Individual Rights completed. 12/20/23- Page numbers added to the form, to help identify if a page is missing. Program Specialists will be retrained on the Regulation and Scanning two-page documents by 1/13/2024. 01/13/2024 Implemented
SIN-00219181 Renewal 02/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(d)Staff person #4 resided outside the Commonwealth of Pennsylvania directly prior to their date of hire, 11/22/22, and has direct contact with individuals. At the time of the 2/22/23 inspection, the facility did not provide an "official" copy of the final report from the FBI. The facility provided an "unofficial copy" of a federal criminal history record information (CHRI) search completed in September 2022.A copy of the final reports received from the State Police, and the FBI, if applicable, shall be kept.Official copy of FBI clearances requested by the HR Generalist, on 2/28/2023. Friendship Community Employment Policy shall be updated by the Associate Director of Human Resources, clarifying that only official FBI clearances shall be accepted. 03/27/2023 Implemented
2380.173(1)(ii)Individual #3's record does not include their identifying marks. Their face sheet states their identifying mark was that they wear glasses. However, glasses can be removed from oneself and is not an identifying marker.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.Individual # 3's face sheet was updated on 2/24/23 to include identifying marks (attachment #1). Day Services Coordinator will retrain Program Specialists in regulation 2380.173(1) (ii) by 4/30/23. 04/30/2023 Implemented
2380.174(b)Individual #1's individual plan kept at the facility was last updated on 5/10/22. At the time of the 2/22/23 inspection, their most recent individual plan was updated on 2/21/23, and has been updated 9 times since 5/10/22. Individual #2's individual plan kept at the facility was last updated on 5/27/22. At the time of the 2/22/23 inspection, the individual's individual plan was last updated on 1/4/23 due to the transfer of service location and needs to the new facility. Their individual plan has been updated 6 times since 5/27/22. Individual #3's individual plan kept at the facility was last updated on 12/5/22. At the time of the 2/22/23 inspection, their most recent individual plan was updated on 1/10/23.The most current copies of record information required in § 2380.173(2)-(11) shall be kept at the facility.3/9/23 most recent copies of ISPs for Individuals #1 (attachment #3 and #4), #2 (attachments #5 and #6), and # 3 (attachments #10 and #11) placed in their records. 04/30/2023 Implemented
2380.181(e)(7)Individual #2's current, 1/14/23 assessment does not include their ability to sense and move away quickly from heat sources. Their assessment indicates they can move away from heat sources independently and that if they were told to move away from a heat source, they would comply. However, the individual is wheelchair bound and the assessment discusses the individual's need for physical assistance occasionally. The assessment does not discuss their ability to move away quickly. Individual #1's current, 1/11/23 assessment does not include their ability to sense and move away quickly from heat sources. Their assessment indicates they can move away from heat sources independently and that if they were told to move away from a heat source, they would comply.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Program Specialist will conduct an audit of all Individual's assessments to assure compliance with regulation 2380.181(e) (7). Addendums created for Individual #1 (attachment #7) 3/10/23 and #2 (attachment #8) 3/13/23. 04/30/2023 Implemented
2380.36(b)The agency did not produce records that Staff persons #1 and #2 received fire safety training specific to the new building location when they first started working with individuals in the new building on 1/9/23. Staff person #1's and #2's most recent training on fire safety was completed on 8/12/22 and 6/30/22, respectively. The trainings were not specific to the new building location to include the new evacuation routes, designated meeting place outside the new location, smoking safety procedures, responsibilities during fire drills, and the location of the smoke detectors and fire extinguishers.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).FC Training Policy shall be updated to specify that new openings require updated fire safety training to include new evacuation routes, designated meeting place outside the new location, smoking safety procedures, responsibilities during fire drills, and the location of the smoke detectors and fire extinguishers. 04/30/2023 Implemented
2380.37(a)The training records for Staff persons #2 and #3 have many hours of training in single days for each staff. Staff person #2 was documented as having 30 hours of training on 2/1/22 and 22 hours of training on 7/14/22. Staff person #3 was documented as having 40 hours of training on 5/19/22. On multiple occasions, Staff persons #2 and #3 are documented as receiving more training hours than there are actual hours in the day.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.FC Training Policy shall be updated to specify that a maximum of 16 hours of training credit can be claimed per day. 03/31/2023 Implemented
2380.39(c)(6)Staff person #1 started working with Individual #3 since the individual's first day on 1/11/23. Staff person #1 did not review the individual's individual plan until 2/22/23. Additionally, there is no documentation that a trainer provided the training of the individual's plan to Staff person #1, but that Staff person #1 completed a reading independently and not in a training session.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Retraining shall be provided by the Associate Director of Human Resources to the Day Services Coordinator regarding the need for training on the ISP to occur for team members prior to Team Member's working with an Individual. This shall be completed by 3/31/23 and documentation of retraining shall be kept on file. 03/31/2023 Implemented
2380.125(f)Individual #2 takes psychotropic medications for a psychiatric diagnosis. Their individual plan does not contain a written protocol to address any social, emotional, and environmental needs of the individuals related to the symptoms of their psychiatric illness. The agency has had Individual #2's 12/22/22 physical examination since that date, that indicates they are now taking a psychotropic medication for a psychiatric diagnosis. The agency did not create a written plan to address the individual's symptoms until 1/16/23, did not update the individual's 1/14/23 assessment to indicate there is now a plan to address the symptoms or update the sections of the assessment that are affected by the change in needs, and did not send the written plan to the team until 1/16/23. At the time of the 2/22/23 inspection, the plan was still not included in the individual's individual plan, nor did the agency reach out to the creator of the plan to ensure the information is included in the individual plan.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.1/16/23 Individual #2's (attachment #9) SEEN plan was sent to the Support Coordinator to be added to the plan. 04/30/2023 Implemented
2380.173(1)(i)Individuals #1 and #2's date of admission to the new facility was not recorded in their records. The date of admission in their records stated 2017, however the facility didn't provide services to individuals until 1/9/2023.The name, sex, admission date, birthdate and Social Security number.2/24/23 Face sheets updated for Individuals #1 (attachment #10) and #2 (attachment #11) with transfer date to new Studio. 03/24/2023 Implemented
SIN-00144374 Renewal 10/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)The locked closet that contained the arts supplies had a large generic spray bottle filled with alcohol.Poisonous materials shall be stored in their original, labeled containers.53(b) Immediate: Immediate retraining was provided to the Day Services Coordinator for Meaningful Day Academy by ODP¿s Licensing Lead while onsite 10/29/2018 regarding the requirement to store poisonous materials in their original, labeled containers as outlined in 53(b) of 2380 regulations. The Day Services Coordinator for Meaningful Day Academy removed the generic alcohol labeled spray bottle from Activities closet on 10/29/2018 and provided retraining to the Activities Professional on appropriate storage of poisonous materials. Global Immediate: The Day Services Coordinator checked all closets where poisons are not typically stored in all Meaningful Day Academy 2380 site locations to ensure that no poisons were present on 10/29/2018. Additionally, all areas where poisons are typically stored were checked by the Day Services Coordinator and Program Assistant to ensure that all poisonous materials were stored in their original, labeled containers by 11/2/2018. Global Preventative: The Activities Professional will clean out Activities closet on a monthly basis to ensure that all products are appropriately labeled. The Day Services Coordinator or Program Assistant will check the contents of the Activities closet during each quarterly Physical Site Inspection to ensure proper storage of poisonous materials in their original, labeled containers. 11/02/2018 Implemented
2380.70(d)The first aid kit located in the kitchen area contained Western Family Triple Antibiotic Ointment and Pain Relief which expired July 2015.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.70(d) Immediate: Immediate retraining was provided to the Day Services Coordinator for Meaningful Day Academy by ODP¿s Licensing Lead while onsite 10/29/2018 regarding the requirement to have a First Aid Kit that contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors as outlined in 70(d) of 2380 regulations. The Day Services Coordinator for Meaningful Day Academy removed the expired supplies from the First Aid Kit on 10/29/2018 and provided retraining to the Program Assistant on the standards for required First Aid contents and expiration dates. Global Immediate: The Day Services Coordinator and Program Assistant checked all First Aid kits at Meaningful Day Academy site locations on 10/29/2018 to ensure that each contained antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. Additionally, the kits were checked to ensure no ointments were present and no expired contents were within any of the kits, and each were verified to be in compliance. Retraining will be provided to the Meaningful Day Academy Team regarding the contents of a First Aid kit by 11/30/2018. Additional training will be provided to the team about the proper of storage and handling of ointments with other medications by 11/30/2018. Global Preventative: The Day Services Coordinator or designee will check the contents of the First Aid Kit, including expiration dates, during each quarterly Physical Site Inspection, which shall occur at least once per calendar quarter starting next quarter, January 2019. The current Physical Site Inspection checklist includes all required items needed in the First Aid Kit. The Day Services Coordinator or Program Assistant will use this as a guide and checklist when completing the Physical Site Inspection. The Day Services Coordinator will retain a copy for program records to ensure quarterly completion of First Aid Kit checks during the Physical Site Inspection. 11/30/2018 Implemented
2380.173(9)Individual #1 9/18/18 assessment states he requires line of sight supervision when using sharp objects due to his erratic movements. This is not documented in his current ISP. His physical 9/20/18 states he has an allergy to Gluten. This is not on his facesheet.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.173(9) Individual #1 Immediate: Immediate retraining was provided to the Day Services Coordinator for Meaningful Day Academy and Associate Director of Operations by ODP¿s Licensing Lead while onsite 10/29/2018 regarding content discrepancies in the ISP, the annual update or revision as outlined in 173(9) of 2380 regulations. The Program Specialist wrote an assessment addendum to address the Individual¿s Supervision Levels in day program, specifically related to the use of sharp objects, after discussion with the Day Services Coordinator, Program Assistant, Networking Ambassador and Associate Director of Operations as of 10/31/2018. The assessment addendum was sent to the Supports Coordinator on 11/1/18. Associate Director of Operations updated the face sheet to include gluten as an allergy for the Individual on 10/29/2018 and provided retraining to the Day Services Coordinator on 10/29/2018 pertaining to required face sheet information on behalf of each Individual. Global Immediate: The Day Services Coordinator, Program Assistant and Program Specialist will review all Individual records by 11/30/2018 to ensure that there are no discrepancies in Individual records, particularly related to behaviors and medical history. If there are any discrepancies noted, records will be updated by the appropriate member of Day Services management by 12/14/2018. The Day Services Coordinator, Program Assistant and Program Specialist will pay specific attention to Individual face sheets to ensure each has been accurately completed for each Individual given the most recent physical examination, medications, medical history and all other relevant documentation. Global Preventative: The Day Services Coordinator or designee will monitor Individuals¿ books on at least a quarterly basis to ensure consistency across Individual records through 6/30/2019; after which, Individuals¿ books will be monitored at least every 6 months. If there are any discrepancies, records will be updated by the appropriate member of Day Services management within 10 working days. The Day Services Coordinator or Program Assistant will sign off on each face sheet as confirmation that the face sheet has been audited and is accurately completed based on current records on file. 12/14/2018 Implemented
2380.183(7)(i)Individual #1 current ISP does not state his potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.183(7)(i) ¿ Individual #1 Immediate: Immediate retraining was provided to the Day Services Coordinator for Meaningful Day Academy and Associate Director of Operations by ODP¿s Licensing Lead while onsite 10/29/2018 regarding the requirement to include vocational programming in the assessment of the Individual¿s potential to advance as outlined in 183(7)(i) of 2380 regulations. The Program Specialist for Meaningful Day Academy contacted Individual¿s Supports Coordinator on 10/29/2018 to discuss an addition to the Educational/Vocational section in the ISP related to the Individual¿s potential to advance. The Program Specialist wrote an addition for the Educational/Vocational Information section after discussion with the Day Services Coordinator, Program Assistant, Networking Ambassador and Associate Director of Operations as of 10/30/2018. The updated information was sent to the Supports Coordinator on 10/31/18. The Program Specialist verified with the Supports Coordinator that the information was updated in the ISP as of 11/6/2018 and the ISP verifies approval of these changes as of 11/8/2018. Global Immediate: The Day Services Coordinator, Program Assistant and Program Specialist will go through all Individual records by 11/30/2018 to ensure that the Educational/Vocational section of the ISP is addressed for each Individual. The Program Specialist will add an Educational/Vocational section to all quarterly assessments starting 11/1/2018. Global Preventative: The Associate Director of Operations will create a quarterly checklist to be completed by the Day Services Coordinator, Program Assistant or Program Specialist by 11/20/2018 to ensure that the assessment of all Individuals¿ potential to advance include vocational programming, community involvement and competitive community-integrated employment. The Associate Director of Operations will train the Day Services Coordinator, Program Assistant and Program Specialist on the new checklist by 11/21/2018. The Day Services Coordinator or designee will use checklist to monitor the inclusion of the Individual¿s potential to advance in vocational programming, community involvement and competitive community-integrated employment in all Individual assessments after 11/20/2018. Individual assessments will be monitored on at least a quarterly basis starting in January 2019 through December 2019; after which, Individual assessments will be monitored at least every 6 months. If there are any discrepancies, assessment amendments will be created and sent by the Program Specialist to the Individual¿s Supports Coordinator within 10 working days. 11/30/2018 Implemented
SIN-00102588 Renewal 11/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #2 did not receive fire safety training upon initial admission to program on 3/16/2016. Individual #2 received fire safety training on 11/2/2016. An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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.Fire safety training is now a mandatory part of the first day curriculum at Meaningful Day Academy for all newly enrolled Individuals. 11/03/2016 Implemented
2380.111(c)(8)Individual #2's physical dated 9/8/2016 did not include physical limitations. The area was left blank. The physical examination shall include: Physical limitations of the individual.Implementation and training of nursing consultant oversight on a quarterly basis for all Individuals' files. Semi annual audits to be completed for all Individuals' files. 11/03/2016 Implemented
2380.181(e)(10)Individual #1's assessments dated 04/15/2016 and 10/25/2016 did not include a lifetime medical history. Both assessments stated "see attached," however no additional documentation was found to be attached to assessments. The assessment must include the following information: A lifetime medical history.Individual #1's assessment was attached on 11/3/16. Semi yearly audits of Individuals' files will be completed. 11/03/2016 Implemented
2380.181(e)(11)Individual #1's assessments dated 04/15/2016 and 10/25/2016 did not include a psychological evaluation. Both assessments stated "see attached," however no additional documentation was found to be attached to assessments. The assessment must include the following information: Psychological evaluations, if applicable.Individual #1's psychological evaluation was attached to lifetime medical and annual assessment on 11/3/2016. The semi annual audits will be completed for all Individuals' files. 11/03/2016 Implemented
2380.183(7)(iii)Individual #1's ISP dated 3/21/2016 did not include an assessment of the individual's potential to advance in the following:  Competitive community-integrated employment. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following:  Competitive community-integrated employment.Overseeing program specialist contacted supports coordinator on 11/4/2016 to add the competitive community-integrated employment information to Individual #1's ISP. 11/04/2016 Implemented
SIN-00213733 Initial review 10/24/2022 Compliant - Finalized
SIN-00184295 Renewal 03/05/2021 Compliant - Finalized
SIN-00161715 Renewal 10/23/2019 Compliant - Finalized
SIN-00123921 Renewal 11/16/2017 Compliant - Finalized
SIN-00087074 Initial review 11/17/2015 Compliant - Finalized