Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00275430 Unannounced Monitoring 10/02/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16(Repeat from 8/26/24, 4/17/25) Individual #1 is 69 years old and receives residential services. They require verbal prompts to initiate their Activities of Daily Living (ADLs) but they are independent in toileting, hygiene, and grooming tasks and will ask for help when needed. The individual requires line-of-sight supervision during mealtimes. According to Individual #1's Lifetime Medical History, the individual was diagnosed with dysphagia on 1/29/19. On 8/15/25, the individual choked during dinner, and the Heimlich Maneuver had to be performed. On 9/10/25, the individual's diet had changed to a Level 7 easy chew diet after the choking incident. A Level 7 chew diet consists of regular easy to chew foods that can be cut or broken apart with the side of a fork or spoon. From the time that the physician had ordered a Level 7 diet on 9/10/25, the individual has been given two sugar free hard candies as a snack every day since 9/11/25 to the current date of 10/3/25. Failure to follow the physician's instructions could pose a choking hazard conducive to serious injury or death due to the individual's dysphagia diagnosis.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.Program Supervisor contacted Geisinger Danville on 10/6/25 and individual #1 is now scheduled for a swallow study on 10/20/25. The Program Supervisor retrained all staff on 10/10/25 in CSG's policies on Abuse and Neglect, Incident Management, Health Services for Individuals in IDD Services, and the requirements of this regulation to ensure understanding in their responsibility to follow prescribed protocols, and reporting incidents according to the IM Bulletin. At this time, staff also received specific retraining in individual #1's diet protocol, including providing education when individual #1 chooses foods that do not align with their diet and could pose a choking hazard. It was reviewed with staff that failure to follow individual #1's diet could lead to another choking incident, which could cause serious injury or death due to individual #1's dysphagia diagnosis. An incident report for neglect was filed in EIM on 10/10/25 for not following individual #1's diet prescribed by their physician. Please see supporting documentation. 11/28/2025 Implemented
6400.141(c)(8)Individual #1 was seen on 6/12/24 and has not had a mammogram since this date, which is outside of the annual time frame.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Program Manager contacted the Breast Center on 10/6/25 and scheduled a mammogram for individual #1 on 10/28/25. Program Supervisor retrained staff on the requirements of this regulation on 10/10/25. Please see supporting documentation. 11/28/2025 Implemented
6400.32(c)(Repeat from 8/26/24 and 4/17/25) At Individual #1's cardiology appointment on 7/9/25, the physician had documented that the individual is to "keep their blood pressure systolic less than 150 with Metoprolol and to notify the physician if their systolic blood pressure is greater than 150. There is not a blood pressure protocol in place and there are no records being maintained verifying that the individual's blood pressure is being monitored. -Individual #1 has a diabetes protocol that their blood sugar levels are tested 2 times daily before meals at breakfast and dinner. The individual's blood sugar level should fall between 80-120 before meals and around 150 2 hours after snacks/meals. If blood sugar level exceeds 150 for at least one week, Teresa Hershberger's office needs to be contacted. If blood sugar level drops under 70 she will receive 4oz fruit juice and recheck level after 15-20 minutes, then offer a light snack. The individual's blood sugar levels are not documented at every testing, which makes tracking the individual's blood sugar level difficult to monitor if the individual's blood sugar level would exceed 150 for at least one week.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.The Program Supervisor contacted individual #1's cardiologist on 10/9/25 for clarification on blood pressure monitoring. A fax was received from the cardiologist on 10/10/25 stating individual #1's blood pressure does not need to be monitored at home. The Program Supervisor retrained all staff on 10/10/25 in CSG's policies on Abuse and Neglect, Incident Management, Health Services for Individuals in IDD Services, and the requirements of this regulation to ensure understanding in their responsibility to follow prescribed protocols, and reporting incidents according to the IM Bulletin. At this time, staff also received specific retraining in individual #1's updated order regarding blood pressure monitoring and individual #1's diabetes protocol. An incident was filed in EIM for neglect on 10/10/25 regarding not following protocols for blood pressure monitoring and diabetes. Please see supporting documentation. 11/28/2025 Not Implemented
6400.213(1)(i)Individual #1's photograph is not current as it was last updated on 9/27/24, which was not updated within the annual time frame to be considered as current.Each individual's record must include the following information: Current PhotoProgram Supervisor updated the photograph of individual #1 in the record on 10/10/25. Staff were trained by the Program Supervisor in the requirements of this regulation that photographs must be updated annually on 10/10/25. Please see supporting documentation. 11/28/2025 Implemented
SIN-00182749 Renewal 02/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed 1/4/21 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-00164872 Renewal 01/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(b)Staff #5 completed fire safety training 05/21/18 and not again until 06/06/19.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).A staff other than staff #5 completed fire safety training on 7/9/18 and 7/8/19. See Fire Safety Training Sign in sheets. All program staff are responsible for maintaining training requirements and are expected to respond to the alerts generated by our training software by registering and attending training.  Employee failure to meet the training requirements of their positions will be subject to corrective action and may not be permitted to work until the requirements are met. Prior to a scheduled leave of absence, employees will review training requirements coming due during the leave of absence and employees will arrange with their supervisor to complete the training in advance of their leave.  On a monthly basis, Managers will review the Monthly Certification Report provided by Human Resources with each of the supervisors during supervision meetings, to discuss each employee¿s registration, schedule and attendance at required trainings.   Supervisors will follow-up with employees to confirm registration and attendance in the appropriate courses to maintain their requirements to continue working.  All employees will be retrained in the training requirements by 6/30/2020.  A quarterly review of a sample of employee training records will be completed by the PDs to be held in July, October, January and April.  A tool for completion of the quarterly review will be developed by 06/15/2020 and PDs will be trained in the tool by 6/30/2020.  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 processes and training tracking. 06/30/2020 Implemented
6400.46(d)Staff #3 was trained in cardio-pulmonary resuscitation (CPR) on 04/06/17 and not again until 05/20/19.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.A DSP staff other than staff #3 completed CPR/First Aid training on 2-15-18 and 2-7-20. See copy of staff CPR/First Aid training certificates. All program staff are responsible for maintaining training requirements and are expected to respond to the alerts generated by our training software by registering and attending training.  Employee failure to meet the training requirements of their positions will be subject to corrective action and may not be permitted to work until the requirements are met. Prior to a scheduled leave of absence, employees will review training requirements coming due during the leave of absence and employees will arrange with their supervisor to complete the training in advance of their leave.  On a monthly basis, Managers will review the Monthly Certification Report provided by Human Resources with each of the supervisors during supervision meetings, to discuss each employee¿s registration, schedule and attendance at required trainings.   Supervisors will follow-up with employees to confirm registration and attendance in the appropriate courses to maintain their requirements to continue working.  All employees will be retrained in the training requirements by 6/30/2020.  A quarterly review of a sample of employee training records will be completed by the PDs to be held in July, October, January and April.  A tool for completion of the quarterly review will be developed by 06/15/2020 and PDs will be trained in the tool by 6/30/2020.  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 processes and training tracking. 06/30/2020 Implemented
6400.52(a)(1)Staff #3 did not complete 24 hours of annual training for training year 2018/2019. She only completed 15.75 hours of acceptable training.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.A staff other than staff #3 completed 24 hours of annual training as of 4/21/20. See copy of staff training transcript. All program staff are responsible for maintaining training requirements and are expected to respond to the alerts generated by our training software by registering and attending training.  Employee failure to meet the training requirements of their positions will be subject to corrective action and may not be permitted to work until the requirements are met. Prior to a scheduled leave of absence, employees will review training requirements coming due during the leave of absence and employees will arrange with their supervisor to complete the training in advance of their leave.  On a monthly basis, Managers will review the Monthly Certification Report provided by Human Resources with each of the supervisors during supervision meetings, to discuss each employee¿s registration, schedule and attendance at required trainings.   Supervisors will follow-up with employees to confirm registration and attendance in the appropriate courses to maintain their requirements to continue working.  All employees will be retrained in the training requirements by 6/30/2020.  A quarterly review of a sample of employee training records will be completed by the PDs to be held in July, October, January and April.  A tool for completion of the quarterly review will be developed by 06/15/2020 and PDs will be trained in the tool by 6/30/2020.  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 processes and training tracking. 06/30/2020 Implemented
SIN-00278377 Renewal 12/01/2025 Compliant - Finalized
SIN-00252578 Renewal 09/30/2024 Compliant - Finalized
SIN-00252669 Renewal 09/30/2024 Compliant - Finalized
SIN-00233945 Renewal 11/14/2023 Compliant - Finalized
SIN-00217439 Renewal 01/06/2023 Compliant - Finalized
SIN-00199565 Renewal 02/07/2022 Compliant - Finalized
SIN-00200163 Renewal 02/07/2022 Compliant - Finalized
SIN-00118976 Renewal 09/18/2017 Compliant - Finalized
SIN-00099207 Renewal 08/01/2016 Compliant - Finalized