Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00291532 Renewal 06/11/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)The preadmission physical dated 8.26.25 recorded negative results of a TB test completed on 3.8.24. The physical and TB must be within 12 months prior to admission, which the TB is outside of that time frame. There must be one valid TB test within 12 months of admission.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.The Director of Nursing set up TB testing for the individual. Copy of test results attached. 06/29/2026 Implemented
2380.171(b)(2)The emergency record did not include the name, address and telephone number of the individual #1 physician or source of healthcare.Emergency information for each individual shall include: The name, address and telephone number of the individual¿s physician or source of health care.Information was added to the record on 6/11/26. Copy of the updated information attached. 06/29/2026 Implemented
2380.176(a)There was individual record books located on tables throughout the day program. These were not locked and were not in use at the time of the inspection.Individual records shall be kept locked when they are unattended.The books were immediately picked up and locked. Photos attached. 07/08/2026 Implemented
SIN-00275536 Renewal 09/30/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #2 and Indvidual #3 were not trained annually in fire safety training. Individual #2 completed annual fire safety training on 1/4/24 and did not receive annual training again until 1/21/25. Individual #3 completed annual fire safety training on 1/4/24 and did not receive annual training again until 1/25/25.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.The individuals were trained beyond 365 days. The Clinical Director has developed a procedure for ensuring completion of Annual Packet of required documents including Fire Safety Training and Education has been developed (attached). Both individuals will be retrained on/before 1/14/26. Completed 10/20/25 10/20/2025 Implemented
2380.21(l)Individual #1, Individual #2 and Individual #3's right to make choices and accept risks was violated. ODP Announcement 24-061 outlines the Federal requirements for individuals to be involved in decision-making about desired community activities, the regulatory requirements in Chapters 2380, 2390 and 6100, and what is required to comply with the regulatory requirements. Providers who deliver Community Participation Support and/or Day Habilitation in Chapter 2380 or Chapter 2390 programs must document conversations in the individual record relating to their preferred community participation and activities at least quarterly. There was no documentation in the individual records of Individuals #1, Individual #2 and Individual #3 that conversations occurred with each of the individuals as required by the ODP Announcement.An individual has the right to make choices and accept risks.Documentation of quarterly conversations regarding desired community activities for individuals. is attached. 10/22/2025 Implemented
2380.126(b)Individual #1 is prescribed Nayzilam Nasal Spray as needed. The medication is not documented on the Medication Administration Record.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Day Program Supervisor corrected the MAR on 9/30/25. A copy of the October MAR is attached. 10/22/2025 Implemented
2380.181(f)Individual #2's assessment did not include a date when the assessment was sent to the individual plan team. It is unknown if the assessment was sent at least 30 calendar days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The Program Specialist corrected the letter (attached). Completed 10/1/25. 10/20/2025 Implemented
SIN-00251207 Renewal 09/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)There were several globs of a charred, black substance consistent in appearance with the burnt drippings of food located on the lower interior surface of the program's kitchen oven. The presence of this substance in the oven constituted a fire hazard for the program.Floors, walls, ceilings and other surfaces shall be free of hazards.The charred, black substance on the lower interior surface of the oven was cleaned immediately by the program staff. Photograph of clean surface was taken. The interior oven surface at another 2380 program (LINKS South) was checked to ensure that it was free from food drippings. The LINKS North 2380 program does not have an oven. 09/17/2024 Implemented
2380.181(f)Individual #1's Individual Assessment was dated 03/14/2024 and the individual's Individual Plan meeting occurred on 03/28/2024. As such, it was not possible for the Program Specialist to provide a copy of the Individual Assessment to members of the individual's Individual Plan team at least 30 calendar days prior to the Individual Plan meeting as required. A letter found in the Individual Record notes that the Individual Assessment was sent to Individual Plan team members on 03/14/2024.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The Assistant Clinical Director reviewed all upcoming assessment dates to ensure that there is sufficient time to complete assessments and forward them to the Supports Coordinator 30 days prior to the annual ISP. 09/18/2024 Implemented
SIN-00231190 Renewal 09/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(b)The first aid area did not have a first aid kit. Violation was corrected at the time of the inspection and a first aid kit was placed in the first aid room.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.First-aid kit was moved to the room identified from the kitchen where the first-aid kit was stored while inspector was still on site. 09/18/2023 Implemented
2380.21(u)The facility did inform and explain individual rights to individuals #1, #2 and #3, but the rights statement that was reviewed with the individuals was not current and/or complete; some rights were missing. Individual #1 was informed on 1/02/2023 and individual #2 was informed on 5/11/2023; the individual rights statement was incomplete and missing 2380.21a. Individual #3 was informed on 1/02/2023 but the rights statement that was reviewed and signed was a chapter 6400 form that was missing the following rights: 2380.21a, 2380.21b, 2380.21c, 2380.21d, 2380.21e, 2380.21f and 2380.21g.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.Updates to the individual rights document occurred on 09/18/2023 to comply with the June 2023 licensing revision noted within the regulatory manual. Updated version was provided to all individuals and individual's guardians for review and signed acknowledgement. 09/18/2023 Implemented
SIN-00211455 Renewal 09/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(b)The electrical outlet in the "sick" room to the left of the door when entering in the room is not free of hazards. The two plug outlet is loose and falling out of the wall.Floors, walls, ceilings and other surfaces shall be free of hazards.Upon identification of the issues the program's facilities maintenance team was contacted regarding the loose outlet. The facilities maintenance team arrived prior to the end of the business day and secured the wall plug. 09/09/2022 Implemented
SIN-00192170 Renewal 09/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.39(c)(6)Staff #1 was not trained in the implementation of the individual plan.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.Staff member has not worked in program since July 2021. If staff member works within the program again the staff member will be expected to immediately comply with Devereux Pocono Standards below. 10/15/2021 Implemented
SIN-00144454 Unannounced Monitoring 10/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16Individual #1 requires a mechanical soft diet with food cut into 1/4 inch pieces. Individual #1's ISP states that Individual #1 requires close monitoring due to being a choking risk, has attempted to ingest a whole banana with peel and a paper napkin when it has been left out, and must be safeguarded from ingesting poisons and other items that may cause a safety hazard. Individual #1's assessment states that Individual #1 should be in visual range at all times and staff may not leave to complete other tasks. On 10/12/18, Individual #1 choked on a whole peanut butter and jelly sandwich which was left at the table Individual #1 was sitting at after lunch. The staff responsible for the supervision of Individual #1 had left the area out of visual range. Individual #1 passed away due to asphyxia, food lodged in airway. Individual #1 was neglected as staff failed to safe guard Individual #1 from items that caused a safety hazard.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.1. Clinical Director to ensure all training and mentoring will be documented. All training will include directives requiring all individuals to be closely monitored during meals. Target date is 11/9/18 and ongoing. 2. Assistant Executive Director and Operations Manager, day programs to assess current group structure of programs and determine if restructuring groups at meal times based on dietary restrictions would be feasible and beneficial. Target date is 11/30/18. 3. Day Program Manager and Operations Managers to assess environment at day and residential programs and make any modifications that will decrease risk at meal times. Examples include not seating individuals that grab food close to easily accessible food, staggering meal times, removing large dining tables and replacing with 2 smaller ones to allow more space at meal times. Target date is 11/09/18. 4. Unfinished meals will be removed from day programs immediately after meal period is complete. Internal trash receptacles will also be emptied after meals to prevent anyone from taking food from them. Residential homes will be assessed, based on need, to determine if secure trash cans should be used. Operations Managers will oversee this process. Target date is 10/12/18 for day programs, 11/16/18 for residential. 5. Operations Managers will ensure that handoff and supervision procedures will be reviewed with staff in all programs by 11/30/18 and then semi-annually in IDT meetings. All reviews will be documented. 6. Addendum will be added to internal monitoring systems (QCG, Internal Group Home Review) to include observation of staff implementing hand-off procedure and requesting a verbal summary of the hand-off procedure from staff. Target date is 11/16/18. 7. Clinical Manager to identify and purchase resources by 12/15/18 to ensure active engagement with individuals when in day programs. More active engagement should help to reduce focus on food. Complete implementation of PBIS in day programs by December 31, 2018. 8. Nursing Director to review all modified diets to ensure appropriateness. Target date is 12/15/18. 9. Client Safety Review Committee, overseen by Assistant Executive Director and Clinical Director, will continue to meet weekly and review all safety incidents including all choking/aspiration incidents as well as prevention strategies. Complete trend analysis regularly for incidents including" OT worked, new versus seasoned staff on duty, pattern of days of occurrences such as Fridays or high call-off days. Target date is 11/12/18 and ongoing. 10. Operations Managers will oversee process of increased drop-ins at all day and residential programs at meal times to ensure staff are following all procedures related to dietary restrictions and supervision during meal times. Target date is 11/12/18 and ongoing. 12/31/2018 Implemented
2380.33(b)(18)During interviews, staff stated they were unaware that Individual #1 would ingest items that were left out in front of him.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual.1. Clinical Director to develop Individual Profile for review at start of each shift. Summary sheet to include significant information such as dietary restrictions, medical needs, behavioral needs, supervision level, communication, diagnoses, allergies, and other risk factors. Individual Profile sheets will be implemented in all day and residential programs. They will be introduced at ATF beginning 11/2/18, Links North and South beginning 11/12/18, and Residential homes beginning 12/1/18. 2. Core staff will continue new hire mentoring where they receive training on individuals in new hire orientation, overseen by Clinical Manager. Target date is 10/12/18 and ongoing. 3. Special diets preparation will continue to be covered in food safety training in new hire orientation and documented, overseen by Facilities Manager. Target date is 10/12/18 and ongoing. 4. All staff who work directly with individuals will complete an annual training "Prevention of Choking and Aspiration". All training will be documented. Target date is 11/30/18 for Learning Manager to have training in place, trainings completed by 12/31/18. 5. Individualized visual prompts of type of diet to be added to each individual's Individual Profile (i.e.- what puree looks like, what dime size pieces look like, etc.). These will be individualized for each person with special diets/choking risks, and overseen by Operations Manager's of both day and residential programs. Target date is 11/30/18 and ongoing. 6. Clinical Specialist to revise TRACER to include thorough review of diets, allergies, choking precautions, meal preparations, and trainings. Target date is 11/23/18. 7. Clinical staff to review current diets, allergies, choking and other precautions from the ISP with residential and day program staff. Target date is 11/23/18. 8. Clinical Specialist to create informational sheets to send to families of day program individuals regarding food choices and choking risks encouraging safe choices in meals sent with these individuals. Target date is 11/30/18. 12/31/2018 Implemented
2380.36(h)The facility does not keep records of staff orientation.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.1. All non-core staff will review, sign and date the Individual Profile to acknowledge training completion prior to working with an assigned individual. This will begin 11/9/18 and be ongoing. 2. All training and mentoring will be documented. All training will include directives requiring all individuals to be closely monitored during meal times. This will begin 11/9/18 and be ongoing. 11/09/2018 Implemented
SIN-00134538 Renewal 05/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's DT booster was late. She had them 09-10-07 and then not again until 11-10-17.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Plan of Correction- Obtaining immunizations added to admissions checklist. Checklist to be used for all new admissions to ensure all documents obtained prior to admission (see attached). Person Responsible- Admissions Director Completion Date- June 8, 2018 and ongoing 06/08/2018 Implemented
SIN-00114458 Renewal 06/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(2)This section was not on the physical exams for Individual #1, Individual #2, and Individual #3. The physical examination shall include: A general physical examination.The Director of Nursing will identify items that should be included in General Physical Exam will be identified and added to the current template. (Please see attachment #2) 07/11/2017 Implemented
2380.173(1)(ii)Identifying marks were not listed in Individual #2's record.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 # 2¿s profile was updated. (Please see attachment 1). A review will be completed with all staff who complete profiles to ensure that all items are completed. 07/07/2017 Implemented
SIN-00100883 Renewal 06/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Direct Service Worker (staff 1) did not have 24 hours of training for the calendar (training) year of 2015. Staff 1 had 21.25 hours for 2015. Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.Managers will continue to review upcoming and mandatory staff training requirements during the monthly team meetings. Progressive disciplinary action will be taken for staff who do not comply with the training requirements. Individual feedback to staff #1 was done on 6/16/16 due to failure to meet training requirement. 09/16/2016 Implemented
2380.89(d)Individual 6 was unable to evacuate the building during the fire drill on 5/26/2016 at 11:58am. This individual refused to evacuate due to significant arthritis pain on this date. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Individual 6 was unable to evacuate the building during the fire drill on 5/26/16 due to arthritis pain. This individual has been able to evacuate the building during fire drill every month since then. Fire drill reports for June, July and August 2016 will be submitted via e-mail as attachment 4, 5 and 6 respectively. Individual 6 is scheduled to have hip replacement on 9/27/16 due to severe chronic arthritis. 09/16/2016 Implemented
2380.111(c)(10)Individual 2's physical dated 1/27/2016 was left blank in the area of information pertinent to diagnosis in the case of emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A cover letter to the physical form is being developed by the Clinical Director. This letter will be submitted to the caregivers and physicians to ensure that they are well informed of the need to have all information on medical evaluation form completed per licensing regulations. The cover letter (attachment #3) will be submitted by 10/31/16. Devereux nurses under the direction of the director of nursing will continue to review completed medical evaluation forms to ensure that all the information required under this regulation has been properly documented by the physicians. The nurses will contact the physician¿s office for any discrepancies. Effective immediately. Chart audits will continue to be completed quarterly by the program specialists and program managers to check for missing information on the forms. Effective immediately. 09/16/2016 Implemented
2380.111(c)(11)Individual 1's physical dated 3/23/2016 had a blank in the area of special diet instructions. The physical examination shall include: Special instructions for an individual's diet.A cover letter to the physical form is being developed by the Clinical Director. This letter will be submitted to the caregivers and physicians to ensure that they are well informed of the need to have all information on medical evaluation form completed per licensing regulations. The cover letter (attachment #3) will be submitted by 10/31/16. Devereux nurses under the direction of the director of nursing will continue to review completed medical evaluation forms to ensure that all the information required under this regulation has been properly documented by the physicians. The nurses will contact the physician¿s office for any discrepancies. Effective immediately. Chart audits will continue to be completed quarterly by the program specialists and program managers to check for missing information on the forms. Effective immediately. 10/31/2016 Implemented
2380.173(1)(ii)Individual 4's record does not contain information on identifying marks. The identifying marks field was left blank in her record. 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.Devereux¿s identification document has a section for `identifying marks.¿ The clinical director reviewed this document with the program specialists on 6/15/16. The program specialists were reminded to complete all sections of the identification document. The Devereux¿s identification card (attachment #2) will be submitted via e-mail. Clinical director and quality management director will do random audits of the consumers¿ charts to ensure that all sections are completed accurately and in a timely manner. Effective immediately. 10/15/2016 Implemented
2380.183(1)Individual 4's ISP was not revised when her needs and services changed on 3/30/2016. Individual 4 stopped attending the Devereux Links program in March of 2016. She began to attend Devereux Clubhouse on 3/30/2016 however, there was no change made to her ISP nor was an ISP review completed to indicate the change in her needs and services. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual¿s plan team.The Clinical team will ensure that ISP revision is completed when an internal transfer happens. The clinical director will monitor internal transfers and coordinate meetings with team members including the supports coordinator to revise the ISP. This is effective immediately. The admission and transfer checklist will be modified to add a section for ISP revision for internal transfers. The modification of the checklist will be completed by 10/31/16. This will be submitted as attachment #1. 10/31/2016 Implemented
SIN-00077554 Renewal 05/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(9)Individual #1 has an Individual Support Plan that states he is not safe with heat sources. His assessment states that he is safe with heat sources.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The SC has been asked to revise the ISP to accurately reflect that the individual is safe with heat sources. Target date 5/21/15 (Please see attachment 1) All program specialists will continue to review ISPs for accuracy. Target Date: 5/21/15 and ongoing 05/21/2015 Implemented
SIN-00055615 Unannounced Monitoring 10/15/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.35(e)Individual #1 requires 1:1 supervision. On 9/2013, Individual #1 went on an outing with Individual #2, Individual #3, and Individual #4. The individuals were accompanied by Staff #1 and Staff #2. Staff #1 was providing 1:1 supervision for Individual #1. During the outing, Staff #1 entered a pizzeria to pick up her lunch leaving the 4 individuals in the supervision of Staff #2. The proper staffing ratio was not maintained. While Staff #1 was in the pizzeria, Individual #2 began having a behavioral outburst which resulted in Individual #1 being struck on the head by Individual #2.(e)  The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c).Individual reviews were completed with the two staff involved in this incident regarding the appropriate supervision levels as outlined in client¿s ISPs. Staff were reminded that these supervision levels must be maintained at all times. Momentary deterrence is not acceptable for any reason including running into a store or restaurant. Additionally, reviews of ISP supervision levels will be completed with all ATF staff by 11/8/13. Documentation of these reviews will be maintained in training files. --Partially Implemented Adequate Progress CH 11/14/13 11/08/2013 Implemented
SIN-00046177 Renewal 03/29/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual 1 had an assessment completed on 2/15/2012. It was not updated annually.(a)  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.Individual 1 had an assessment completed on 3/29/13. Tracking is currently in place to ensure that assessments are completed within necessary timeframes. A clerical error resulted in the due date being entered incorrectly resulting in the noted time lapse. The clinical director will ensure all program specialists review timelines for accuary. -Fully Implemented CH 4/23/13 03/29/2013 Implemented
SIN-00156800 Renewal 05/29/2019 Compliant - Finalized
SIN-00060017 Renewal 03/05/2014 Compliant - Finalized