Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244053 Unannounced Monitoring 04/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)At the time of the 4/15/24 inspection, there was not a current and up-to-date financial record at the home. In April 2024, there were two math errors that were never reconciled. The cash balance was documented as $3.52. The actual cash balance at the time of inspection was $2.61.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. April 2024 financial record was completed by the Program Supervisor and mathematical errors found were corrected on 4/16/24. Funds were audited by the Program Supervisor and Program Manager on 5/6/24 (attachment #1). Staff were trained by the Program Supervisor in keeping an up to date financial and property record for individuals, including personal possessions and funds received by or deposited with the home on 5/16/24 (attachment #2). 06/20/2024 Implemented
6400.43(b)(1)At the time of the 04/15/24 physical site inspection, two plastic water bottles full of discarded cigarettes and an accumulation of ash were found on the front porch. Staff at the home stated that there is to be no smoking on provider properties.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Plastic water bottles containing discarded cigarettes and ash were disposed of on 4/15/24 (attachment #4). All staff were retrained on CSGs Tobacco Free Workplace policy on 5/16/24 (attachment #2). 06/20/2024 Implemented
6400.80(a)At the time of the 04/15/24 physical site inspection, the front concrete porch had a deep crack and was detached from the first stair, creating tripping hazards. Outside walkways shall be free from ice, snow, obstructions and other hazards. The front concrete porch was repaired on 5/8/24 (attachment #6). 06/20/2024 Implemented
6400.80(b)At the time of the 04/15/24 physical site inspection, both rear window wells were rusted through and the siding on the rear of the home was covered in a dark substance. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The rear window wells were replaced and the home was pressure washed on 5/8/24 (attachment #7). 06/20/2024 Implemented
6400.144Individual #1 is prescribed 600mg of Ibuprofen as needed. At the time of the 4/15/24 inspection, only 200mg of Ibuprofen was available for Individual #1.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1s PCP was contacted by the program supervisor on 5/2/24 due to the need for ibuprofen 600mg. It was discussed with the PCP office that since individual #1 has not had a need for ibuprofen, the PCP discontinued this medication on 5/2/24 (attachment #8). 06/20/2024 Implemented
6400.32(c)Individual #1's PCP indicated that the individual should be eating no more than 3000 calories per day until 2/27/24, when this recommendation changed to no more than 2400 calories per day due to the increase in Individual #1's weight. Additionally, Individual #1 is to be exercising at least 30 minutes per day and taking at least 10,000 daily steps. Individual #1 frequently refuses to exercise and take their daily recommended steps. They also frequently exceed their daily calories. Individual #1 was 382.4 pounds on 1/1/24, and, by 4/1/24, their weight had increased to 396 pounds. Community Services Group was to implement a plan of correction by 12/18/23 that included a desensitization plan to address Individual #1's frequent refusals of daily exercise and steps. Additionally, Individual #1 has exceeded their daily caloric intake goals on 55 days from 1/1/24 through 4/8/24, with daily calories reaching 6412 calories. As of the 4/4/24 inspection, Individual #1 is still not being educated on the importance of exercise, daily steps, and staying below daily caloric recommendations from the PCP. Individual #1 has gained nearly 14 pounds in the last 3 months. Failure to implement plans to address refusals and ensure that Individual #1 is adhering to diet recommendations puts Individual #1's health at serious risk.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.The Behavior Specialist completed training with all staff on 5/9/24, providing education on documentation requirements (attachment #3). This includes where and how to document refusals to complete daily recommended steps and staying below daily caloric recommendations from the PCP, and the education to be provided as a result of the refusals. During this 5/9/24 training, the Behavior Specialist elicited input from the team regarding effective approaches with individual #1. Individual #1's team does not believe that a desensitization plan will be the best approach due to their diagnosis of oppositional defiant disorder. The Behavioral Specialist has completed a restrictive token DRA plan to assist in encouraging individual #1 to follow diet and exercise recommendations, which was submitted and approved by HRT (Attachment #13). Staff will be trained on the plan on 5/30/24 and the plan will be implemented on that date (Attachment #14). The Program Director provided training to the Program Specialist on CSGs Policy and Procedure for Health Services for Individuals in Intellectual and Developmental Disability Services C.7.e-IDD (Attachment #17) on 5/29/2024 (Attachment #15) to promote person-centered physical healthcare practices that aim to proactively address health issues and reduce the risk of harm to individuals. These practices include supporting and educating individuals on their physical health conditions and following medical recommendations. The Program Specialist trained all staff, Program manager and supervisor on this policy 5/30/24 (Attachment #16). 06/20/2024 Implemented
6400.50(a)Staff persons #1, #3, #4, #5, #6, #8, and #9 have all received medication administration training via routes other than oral, however, the training records kept do not have all the required information. The information required by the medication administration training course includes: staff person name, initial qualification date, most recent annual practicum date, names of non-oral meds staff person received training on and date for each, staff person signature and date, and training provider name, signature and date.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Staff were trained by the Program Nurse on 5/16/24 in routes other than oral and training records will contain the required information (attachment #2). It was communicated to CSG Medication Trainers 5/7/24 that training records need to contain this information moving forward (attachment #5). 06/20/2024 Implemented
6400.52(c)(6)Individual #1 has an Individual Support Plan (ISP) and Behavior Support Plan (BSP) that staff are to be trained on before working with the individual. Staff persons #7 and #9 have not received training on Individual #1's ISP. None of the 9 staff persons who have worked with Individual #1 since 1/1/24 have been trained on Individual #1's BSP.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.All staff will be trained on individual #1s ISP and behavior support plan by 5/30/24 (Attachment #14; Attachment #16). 06/20/2024 Implemented
6400.163(h)At the time of the 4/15/24 inspection, the following expired medications were in the home: Fiber, Loratadine, and Promethazine.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Expired medications were disposed of on 5/2/24 (attachment #9). Individual #1s PCP was contacted by the program supervisor on 5/2/24 due to the need for Promethazine and Fiber. It was discussed with the PCP office that since individual #1 has not had a need for Promethazine, the PCP discontinued this medication on 5/2/24 (attachment #8). The Fiber was refilled and obtained on 5/2/24 (attachment #10). 06/20/2024 Implemented
6400.167(a)(4)There have been many occasions where Individual #1's medications have been administered more than an hour before or an hour after the prescribed administration time. · 1/1/24 -- 6am medications administered at 8:01am · 1/2/24 -- 6am medications administered at 7:12am · 1/3/24 -- 6am medications administered at 7:47am; 6pm medications administered at 7:12pm · 1/4/24 -- 6am medications administered at 7:44am · 1/12/24 -- 6am medications administered at 7:34am; 6pm medications administered at 7:10pm · 1/13/24 -- 6am medications administered at 9:39am; 8am medications administered at 9:26am · 1/14/24 -- 6am medications administered at 7:48am · 1/15/24 -- 6am medications administered at 8:34am · 1/16/24 -- 6am medications administered at 7:36am · 1/17/24 -- 6am medications administered at 7:06am; 6pm medications administered at 7:10pm · 1/18/24 -- 6am medications administered at 8:36am · 1/22/24 -- 6pm medications administered on 1/23/24 at 5:18pm · 1/26/24 -- 6am medications administered at 7:09am · 1/27/24 -- 6am medications administered at 8:05am · 1/28/24 -- 6am medications administered at 7:36am · 1/29/24 -- 6am medications administered at 7:31am · 1/30/24 -- 6am medications administered at 9:21am; 8am medications administered at 9:19am · 1/31/24 -- 6am medications administered at 8:42am · 2/1/24 -- 6am medications administered at 7:28am · 2/9/24 -- 6am medications administered at 7:23am · 2/10/24 -- 6am medications administered at 7:53am; 6pm medications administered at 7:06pm · 2/11/24 -- 6am medications administered at 7:44am; 6pm medications administered at 7:27pm · 2/13/24 -- 6am medications administered at 7:48am; 6pm medications administered at 7:11pm · 2/14/24 -- 6am medications administered at 7:41am; 6pm medications administered at 7:06pm · 2/15/24 -- 6am medications administered at 7:20am · 2/23/24 -- 6pm medications administered at 7:27pm · 2/24/24 -- 6am medications administered at 7:55am; 6pm medications administered at 7:02pm · 2/25/24 -- 6am medications administered at 7:53am; 6pm medications administered at 7:10pm · 2/26/24 -- 6am medications administered at 8:20am; 6pm medications administered at 7:19pm · 2/27/24 -- 6am medications administered at 7:06am; 6pm medications administered at 7:19pm · 2/28/24 -- 6am medications administered at 7:15am · 2/29/24 -- 6am medications administered at 7:49am · 3/9/24 -- 6am medications administered at 7:24am · 3/10/24 -- 6am medications administered at 8:05am · 3/11/24 -- 6am medications administered at 7:14am · 3/12/24 -- 6am medications administered at 7:22am · 3/13/24 -- 6am medications administered at 8:28am · 3/14/24 -- 6am medications administered at 7:24am · 3/17/24 -- 6pm medications administered at 7:01pm · 3/20/24 -- 6pm medications administered at 7:22pm · 3/22/24 -- 6am medications administered at 7:11am · 3/23/24 -- 6am medications administered at 8:19am; 6pm medications administered at 7:19pm · 3/24/24 -- 6am medications administered at 7:49am · 3/25/24 -- 6am medications administered at 7:24am; 6pm medications administered at 7:23pm · 3/26/24 -- 6am medications administered at 8:00am; 6pm medications administered at 7:03pm · 3/27/24 -- 6am medications administered at 7:41am · 3/28/24 -- 6am medications administered at 7:20amMedication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.All staff were trained by the Program Nurse on 5/16/24 regarding administering medications and signing off on the MAR in the timeframe that is allowed under the Medication Administration Guidelines (attachment #12). 06/20/2024 Implemented
6400.167(c)The medication errors described in 6400.167a4 were not reported in the department's incident management system.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Medications errors were entered into the EIM system by the Program Manager on 5/9/24 (attachment #11). 06/20/2024 Implemented
6400.186Individual #1 has a behavior support plan dated 7/24/23 to address the following behaviors: stealing, physical aggression, property destruction, intentional voiding, verbal aggression, verbal/physical threats, food seeking, self-injurious behavior, refusal, passive aggressive behavior, inappropriate sexual behavior, boundary challenges, false allegations, suspected non-compliance with shower, decreased energy, decreased interest in pleasurable activities, increased use of self-stimulation/psychomotor agitation, sleep disturbance, and weight/appetite change. With every behavior, staff are to document the type of behavior, redirection methods, and Individual #1's response. There were 32 times between 1/1/24 and 4/8/24 that behaviors were noted, but there was no further information recorded. It is not known if staff implemented Individual #1's behavior support plan, which methods of redirection were used, and what Individual #1's response was to this redirection.The home shall implement the individual plan, including revisions.The Behavior Specialist completed training with all staff on 5/9/24, providing education on documentation requirements per individual #1s behavior support plan (attachment #3). 06/20/2024 Implemented
SIN-00233906 Renewal 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(12)Individual #1's most recent physical completed on 2/21/23 did not include information on Individual #1's physical limitations. This section was left blank.The physical examination shall include: Physical limitations of the individual. The physical form was returned to the physician and the physical limitations section was completed on 12/11/23. Staff were trained on the requirement of this regulation on 12/8/2023. See supporting documentation. 12/18/2023 Implemented
6400.141(c)(14)Individual #1's most recent physical completed on 2/21/23 did not include the information pertinent to treat or diagnose in the event of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical form was returned to the physician and the information pertinent to treat or diagnose in the event of an emergency was completed on 12/11/23. Staff were trained on the requirement of this regulation on 12/8/23. See supporting documentation. 12/18/2023 Implemented
6400.143(a)Individual #1 refused to complete exercises and daily steps ordered by a medical professional in the month of July 2023; there is no refusal plan to address this in the record.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Special procedure/refusal plan was updated to include how to handle/address refusals and the need for detail in the daily notes/documentation. Staff training occurred on 11/30/2023 See Supporting documentation. 12/18/2023 Implemented
6400.144Individual #1's Bowel Movement tracking did not document whether they had a bowel movement when they were at day program during the month of July. Individual #1 is not to have more than 3000 calories a day. From February 2023 through October 2023, Individual #1 had more than 3000 calories a total of 107 times. The highest caloric intake in one day was 6203, more than twice the allowable amount. In addition, there were at least ten days in which the calories were not counted for all the meals.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Staff were retrained on the need for documentation on 12/7/2023 for bowel movements and caloric intake. See supporting documentation. 12/18/2023 Implemented
6400.163(h)At the time of the inspection there was an expired bottle of Ammonium Lactate available in the home. It had expired on 9/19/23.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The expired bottle of Ammonium Lactate was disposed of and the other bottle remains with an expiration date 7/5/2024. All staff were trained to check all medication expiration dates monthly on 12/8/2023. See supporting documentation. 12/18/2023 Implemented
6400.167(a)(1)Individual #1 was diagnosed with a UTI on 10/6/23. They were prescribed Bactrum to be taken twice a day. On 10/12/23, staff realized Individual #1 was not receiving their morning dose of Bactrum.Medication errors include the following: Failure to administer a medication.Program Supervisor was trained to ensure all medications are entered correctly in the medication log and medication log will be checked daily and each time a new medication is prescribed. Program Supervisor was trained on 12/8/23. See supporting documentation. 12/18/2023 Implemented
SIN-00182698 Renewal 02/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed 1/21/21 did not include a written summary of corrections.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. All self-assessments will be updated with the written corrective measures taken for each citation. This will be completed by 5/31/21. Directors, PDs, Managers and Specialists will schedule events and alerts in Google Calendars by 5/31/2021 to indicate the start and completion dates for the annual self-assessments, which will be completed 3-6 months prior to the license date of 5/13. The start date will be 11/13/2021 and the completion date will be 2/12/2022. Each event will be set to repeat annually. Upon completion of self-assessments and prior to the due date of 2/12/2022, PDs will schedule a meeting with the Managers and Specialists to review the self-assessments and plans of correction to ensure the plan of correction is written in the self-assessment. All PDs, Managers and Specialists will be retrained in the requirement to include written plans of correction in the self-assessment by 5/31/21. 05/31/2021 Implemented
SIN-00164821 Renewal 01/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Per individual #1's updated IP, on 10/31/2018 he was seen by Dr. , due to darkening patches of skin on his hands and arms. The diagnosis was photosensitivity rash due to sun damage and dry skin. Dr. prescribed lac-hydrin (ammonium lactate) lotion to be applied to individual #1's hands and arms twice daily to help with dry skin. Individual #1 was instructed to apply SPF 30 when outside in the sun to all uncovered skin. No other follow up needed. This SPF 30 was not at individual #1's home and has not been documented as applied when he was outside in the sun.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 was seen by doctor on 1/31/20 for reevaluation of darkening patches of skin. The darkening patches were discovered to be dirt and not a result of sun damage. Individual #1 only needs sunscreen during spring and summer months which the home keeps on hand in the first aid kit. Program Specialist emailed Supports Coordinator to update ISP with this information on 4/21/20. See copy of email to Supports Coordinator and copy of medical appointment form. Upon reports from direct service employees and/or reviews of notes and documents pertaining to health services, Supervisors, Managers and Specialists will reach out to the Health Services Coordinator to discuss changes in an individuals health services and care needs. The Health Services Coordinator will complete or coordinate the completion of a review of the individuals record and medical/health condition. The Health Services Coordinator will work with the Specialist for the coordination of planned or prescribed services included in the regulation, which may include follow-up with medical professionals and require training for staff. All records will be reviewed by the Specialists to ensure health services as outlined in this regulation that are planned or prescribed for individuals will be arranged for or provided and will be completed by 7/31/2020. CSGs Continuous Quality Improvement Coordinator will meet with the Specialists on a monthly basis to provide standardized processes and training for completion of assessments and ISPs and clarifying roles and responsibilities of the Specialist position, including reviews of services and treatments planned or prescribed. The Continuous Quality Improvement Coordinator will work with the Specialists on the quarterly review process for a sampling of record reviews for the programmatic components. Quarterly reviews of a sampling of records will also be completed by CSG¿s Health Services Coordinator. The tools and procedures for the completion of the record reviews will be developed by June 15, 2020 to include the requirements of this regulation. PDs and Directors will review the outcomes of the quarterly sample reviews by the end of July, October, January and April to determine any necessary improvements in policies, procedures and training needs. PDs, Specialists, Managers and Supervisors will be retrained in the requirements of this regulation and plan of correction by 6/30/2020. 07/31/2020 Implemented
SIN-00079121 Renewal 04/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The dresser belonging to Individual #1 is missing a knob from the top dresser drawer. Floors, walls, ceilings and other surfaces shall be in good repair. The knob on the dresser belonging to Individual #1 was replaced. A photo of the dresser with the knobs is attached and labeled as Attachment #1-SIN-00079121-212 Cider Press Rd, Lock Haven, Pa 17745-67(a) 05/30/2015 Implemented
6400.80(b)The walk way near the driveway, on the side of the house, has a large crack creating a tripping hazzard for the individuals in the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The walkway near the driveway was patched to repair the large crack near the driveway and eliminate the tripping hazard. A picture of the patched sidewalk is attached and labeled as Attachment #1 SIN-00079121-212 Cider Press Rd, Lock Haven. Pa 17745-80(b) 05/30/2015 Implemented
SIN-00252540 Renewal 09/30/2024 Compliant - Finalized
SIN-00252632 Renewal 09/30/2024 Compliant - Finalized
SIN-00217393 Renewal 01/06/2023 Compliant - Finalized
SIN-00199517 Renewal 02/07/2022 Compliant - Finalized
SIN-00200112 Renewal 02/07/2022 Compliant - Finalized
SIN-00118920 Renewal 09/18/2017 Compliant - Finalized
SIN-00099195 Renewal 08/01/2016 Compliant - Finalized