Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00282934 Renewal 02/12/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2's physical examinations were completed on 11/22/2024 and again on 12/11/2025. Individual #3's most recent physical examination was completed on 10/30/2024.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Chapter 2380.111 (a): Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. The Vocational Director and Program Specialist that oversee the ATF program ensure that all physicals are completed by performing bi annual checks to ensure that all physical dates are in good standing. Individual 3 was notified on Feb. 13th that he was not allowed to return until physical was completed. 02/13/2026 Implemented
2380.111(c)(3)Individual #1's most recent tetanus, diphtheria, and pertussis vaccination was administered on 10/22/2015. Individual #3's most recent tetanus, diphtheria, and pertussis vaccination was administered on 03/01/2015. The Unites States Public Health Service, Center for Disease Control recommends adults to receive the tetanus, diphtheria, and pertussis vaccination every 10 years.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Chapter 2380.111 (c)(3). The physical examination should include: Immunizations as recommended by the United States Public Health Service, Center for Disease Control, Atlanta, Georgia 30333. The Vocational Director and ATF program specialist ensure that all physicals and checked thoroughly for completeness and including all recommendations from the CDC. * Vocational Director called parent and or guardian and advised to have an updated tetanus vaccination on 2/23/2026. 02/23/2026 Implemented
2380.113(a)Direct Service Worker #2 completed their biennial physical examinations on 01/24/2023 and again on 11/23/2025.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Chapter 2380.113 (a) A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6 month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every two years thereafter. HR Director has updated all staff physicals dates in Paycom notification system. 02/23/2026 Implemented
2380.36(b)Direct Service Worker #3 participated in training to encompass general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility or within the fire safe area, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered on 06/01/2023 and again on 04/04/2025.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Chapter 2380.36 (b): Program specialist and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). The Vocational Director and Training Coordinator will work together to ensure that fire safety is completed annually. Direct Service Worker completed fire safety training on Feb.13th. All staff are current. 02/13/2026 Implemented
2380.37(a)Program Specialist #1 participated in training to encompass general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility or within the fire safe area, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered on 05/22/2025; however, the record for this training did not include the length of the training.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Chapter 2380.37 (a): Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. The Vocational Director and Training Coordinator will ensure that all areas listed above will be present on the training documentation. This will ensure that all areas are met according to regulation. Program Specialist had fire safety training on Feb 13th that listed all specifications as required. 02/13/2026 Implemented
SIN-00263226 Renewal 03/27/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(3)Direct Service Worker #1's physical examination completed 2/17/25 did not include a signed statement that the person is free of serious communicable diseases.The physical examination shall include: A signed statement that the person is free of serious communicable diseases 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, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.Chapter 2380.113(c)(3) - A signed statement that the person is free of serious communicable diseases. All staff physicals will be thoroughly checked by the Vocational Director and Human resources director before being accepted. If any areas of the physical are in question of not being filled out correctly, the staff member will need to have those areas of question filled out correctly. 03/28/2025 Implemented
SIN-00223235 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #3, date of admission 11/30/2022, had a physical examinatio0n completed 12/12/2022.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.All program specialist have received training in Chapter 2380.111 (a). Individual # 3 going forward will have physicals done on time and annually thereafter. 04/27/2023 Implemented
2380.111(c)(4)Individual #3's physical examination completed 12/12/2022 did not include a hearing and vision screening. It was left blank. Individual #4's physical examination completed 2/28/2023 documents a vision and hearing screening are recommended and there is no documentation of a follow-up since.The physical examination shall include: Vision and hearing screening, as recommended by the physician.All program specialist have received training in Chapter 2380.111 (c)(4). Individuals 3 and 4 will have their physicals updated. Attempts will be made to contact house staff/guardians to have physicals corrected. 04/27/2023 Implemented
2380.111(c)(5)Individual #3, date of admission 11/30/2022, had a Tuberculin skin test read 12/15/2022.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.All program specialists have received training on Chapter 2380.111(c)(5). all individuals will have TB read in time allotment required by regulations before being admitted into the program. 04/27/2023 Implemented
2380.113(c)(2)Direct Service Worker #1, date of hire 5/02/2022, has not had an initial Tuberculin skin test.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.All Staff will be required to have a physical and Negative TB result before hire. All physicals will be completed in writing by medical staff allowed to give and read the result. 04/27/2023 Implemented
2380.181(a)Individual #2 had an assessment completed 1/14/2022 and then again 2/03/2023.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.All program specialist have received training on Chapter 2380.181(a). All individual(s) will have their initial assessments done within 1 year prior to or 60m calendar days after admission to the facility and an updated assessment annually thereafter. 04/27/2023 Implemented
2380.182(c)Individual #1's assessment completed 3/24/2023, Individual #2's assessment completed 2/03/2023, Individual #3's assessment completed 11/30/2023, and Individual #4's assessment completed 3/24/2023 were copied directly from the individuals' individual support plan.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.All program specialist have received training on chapter 2380.182(c). All individuals plans will be developed, revised annually and revised when an individual's needs change based upon a current assessment. 04/27/2023 Implemented
SIN-00241810 Renewal 03/28/2024 Compliant - Finalized
SIN-00204396 Renewal 05/03/2022 Compliant - Finalized
SIN-00187047 Renewal 05/06/2021 Compliant - Finalized
SIN-00161689 Renewal 08/27/2019 Compliant - Finalized
SIN-00163588 Renewal 08/27/2019 Compliant - Finalized