Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249716 Renewal 08/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)There was bleach in an unlocked cabinet under the sink in the kitchen as well as Lysol spray and dry erase cleaner in an unlocked cabinet in the unlocked program managers office at the time of the inspection.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.In accordance with 55 PA Code Chapter 2380.53 (a) the bleach, Lysol spray and dry erase cleaner that were kept in an unlocked cabinet (only secured by a child safety lock) were moved to cabinets with a full lock. (Attachment #1-pictures) Director, completed another sweep of the entire building to ensure there were no other poisons that were unlocked. This was documented on the updated Site Inspection form (Attachment #2-form) that is completed at least monthly by the Program Manager (or Director). All staff were retrained on safe storage of poisonous materials. (Attachment #3-training records) 08/29/2024 Implemented
2380.176(a)There were individual records on the table in the unlocked program managers office at the time of the inspection.Individual records shall be kept locked when they are unattended.In accordance with 55 PA Code Chapter 2380.176 (a) the files that were left on the table in the unlocked office were placed in the locked file cabinet until which time they could be filed and returned to the locked cabinet. (Attachment #1-pictures) Director, completed a sweep of the offices and the rest of the building to ensure there were no other files left unattended and unlocked. This was documented on the updated Site Inspection form (Attachment #2-form) that is completed at least monthly by the Program Manager (or Director). All staff were retrained on the access to individual records policy. (Attachment #3-staff training records) 08/29/2024 Implemented
SIN-00231017 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.38(a)(1)Staff #2 was hired on 9/5/2023 and began working with individuals but has not completed the ODP Orientation, [see regulation 2380.38b] (to include: individual rights, abuse: detection, reporting and prevention of abuse, suspected abuse and alleged abuse, Person Centered Practices; community integration, Individual choice; Developing and maintaining relationships, Recognizing and Reporting incidents) that is required to be completed prior to working with individuals.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.Regarding Regulation 2380.38a Staff #2 completed the ODP orientation on 9/15/23 upon discovery of the error and prior to working any further with individuals. The training included individual rights, abuse: detection, reporting and prevention of abuse, suspected abuse and alleged abuse, Person Centered Practices; community integration, Individual choice; Developing and maintaining relationships, Recognizing and Reporting incidents (Attachment #1- certificates of completed ODP training) Supervisory staff to include the Director, Community Participation Manager and Program Manager was retrained on 9/25/23 on the Life Time Training plan which outlines the regulation 2380.38a. (Attachment #2-Staff sign off and copy of training received) Staff #2 is the first new staff hired since the adoption of this regulation in 2019 so no other staff records were relevant to review. 09/25/2023 Implemented
SIN-00210959 Renewal 09/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(6)Individual #1 physical did not list if the individual was free of communicable disease.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.Regarding regulation 2380.111.c.6 Individual #1s physical examination was updated to reflect that he is free from communicable disease. (Attachment #1) All staff were retrained on the items required for each physical. (Attachment #2) All other 2380 client files were rechecked to be certain this information is included on their latest physical examination. (Attachment #3). 09/19/2022 Implemented
2380.111(c)(8)Individual #1 physical did not list physical limitations.The physical examination shall include: Physical limitations of the individual.Regarding Regulation 2380.111.c.8 Individual#1s physical examination was updated to reflect his physical limitations. (Attachment #1). All staff were retrained on the items required for each physical. (Attachment #2) All other 2380 client files were rechecked to be certain this information is included on their latest examination. (Attachment #3) 09/19/2022 Implemented
2380.111(c)(10)Individual #1 physical did not list information in case of a emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Regarding Regulation 2380.111.c.10 Individual #1s physical examination was updated to reflect his medical information pertinent to diagnosis and treatment in case of an emergency. (Attachment #1). All staff were retrained on the items required for each physical. (Attachment #2) All other 2380 client files were rechecked to be certain this information is included on their latest examination. (Attachment #3) 09/19/2022 Implemented
2380.173(1)(ii)Individual #1's record did not contain identifying marks.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.Regarding Regulation 2380.173.1.ii Individual #1s Personal information form was updated to reflect his identifying marks (Attachment #5). All staff were retrained on the items required on each personal information form. (Attachment #2) All other 2380 client files were rechecked to be certain this information is included on personal information form. (Attachment #3) 09/19/2022 Implemented
SIN-00192863 Initial review 09/14/2021 Compliant - Finalized