Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00223177 Renewal 04/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Direct Service Worker #2, date of hire 3/11/2023, did not have a Pennsylvania criminal history record check completed within the last 12 months. [Repeat Violation, 5/5/2022]An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Program specialist requested updated documentation from staffing agency before staff's hire date. They provided clearances that were in compliance for their agency but not the program site. Program specialist reached out to staff and requested updated documentation. 06/09/2023 Implemented
2380.53(a)At 2:37PM, a spray bottle of Contact Plus One-Step Disinfectant Cleaner, a container of Steramine Tablets and Sani-Cloth Germicidal Disposable Wipes were in the unlocked cabinet under the sink in the main program area. At 2:47PM, a spray bottle of Contact Plus One-Step Disinfectant Cleaner and Sani-Cloth Germicidal Disposable Wipes were on shelves in the bathroom. All of these cleaning products had directions to contact Poison Control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Staff was unaware of regulations regarding poisonous substances. During staff meeting, program specialist re-trained all staff on state regulations regarding poisonous substances / materials. Program specialist conducted walkthrough in main program area and bathroom and collected all poisonous materials and put them away in locked cabinets. A lock was requested on the cabinet beneath the sink in the nursing area and was installed within the week. All staff and personnel who use the program bathroom after program hours and who re-stock the bathrooms materials including cleaning supplies were informed of state regulations regarding poisonous materials and best practices to remain in compliance. They were informed on the location of where all poisonous materials will be stored when not in use. 05/24/2023 Implemented
2380.111(c)(3)Individual #1's most recent Tetanus immunization was administered on 7/28/2012. Individual #3's most recent Tetanus immunization was administered on 7/28/2012.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Program specialist was unaware of regulations pertaining to immunizations. Program specialist will complete training on regulations regarding immunizations and how often they need to be completed. Program specialist will inform families of participants who are out of compliance with their immunizations and request their immunizations for tetanus to be completed as soon as possible. 06/09/2023 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 9/14/2022, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. Individual #2's physical examination, completed 2/23/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. [Repeat Violation, 5/5/2022]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program specialist missed the section regarding information pertinent to diagnosis during documentation review. Documentation checklist was not utilized either. Program specialist will review physicals with families and request completion. 06/09/2023 Implemented
2380.113(a)Direct Service Worker #2, date of hire 3/15/2023, completed her most recent physical examination on 6/14/2021. Direct Service Worker #3, date of hire 3/15/2023, did not complete a physical examination. [Repeat Violation, 5/5/2022]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.Program specialist requested documentation for agency staff prior to start date. Agency was able to provide some documentation but not all. Program specialist did receive physical information for DSP #3 but it was not sufficient documentation according to state regulations and it was discovered upon review that the documentation that was received was out of date anyway. Though the information received was in compliance for the agency it was not in compliance for program site. Program specialist will request updated physicals for DSP's immediately. 06/09/2023 Implemented
2380.181(a)Individual #1, date of admission 9/27/2022, had an initial assessment completed on 12/1/2022. Individual #2's most recent assessment was completed 1/19/2022. Individual #3's most recent assessment was completed 2/3/2022.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.Program specialist thought the initial review timeline didn't include holidays resulting in a late initial review. For other individuals missing assessments, it was discovered upon review that program specialist did not have reminders adequately established in online calendar. Because alerts were missed it resulted in late assessments. Upon discovery, the assessments were completed immediately and reviewed with individuals. Completed assessments were submitted to ISP team and proof of submission was placed in binders. 06/09/2023 Implemented
2380.39(c)(1)Chief Executive Officer #1's trainings for the annual training year, 8/1/2021 through 7/31/2022 did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Program specialist was unaware that the CEO needed training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships since they do not have direct contact with participants on a daily basis. It was assumed that CEO's needed only 12 hours of training. Program specialist ensured the required number of hours of training were completed but not what training was needed to ensure compliance. Program specialist will request the training be completed by June 9, 2023. 06/09/2023 Implemented
2380.39(c)(2)Chief Executive Officer #1's trainings for the annual training year, 8/1/2021 through 7/31/2022 did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Program specialist was unaware that the CEO needed training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations since they do not have direct contact with participants on a daily basis. It was assumed that CEO's needed only 12 hours of training. Program specialist ensured the required number of hours of training were completed but not what training was needed to ensure compliance. Program specialist will request the training be completed by June 9, 2023. 06/09/2023 Implemented
2380.39(c)(3)Chief Executive Officer #1's trainings for the annual training year, 8/1/2021 through 7/31/2022 did not include individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Program specialist was unaware that the CEO needed training on individual rights since they do not have direct contact with participants on a daily basis. It was assumed that CEO's needed only 12 hours of training. Program specialist ensured the required number of hours of training were completed but not what training was needed to ensure compliance. Program specialist will request the training be completed by June 9, 2023. 06/09/2023 Implemented
2380.39(c)(4)Chief Executive Officer #1's trainings for the annual training year, 8/1/2021 through 7/31/2022 did not include recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Program specialist was unaware that the CEO needed training on recognizing and reporting incidents since they do not have direct contact with participants on a daily basis. It was assumed that CEO's needed only 12 hours of training. Program specialist ensured the required number of hours of training were completed but not what training was needed to ensure compliance. Program specialist will request the training be completed by June 9, 2023. 06/09/2023 Implemented
SIN-00204748 Renewal 05/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Direct Service Worker #2, date of hire 3/16/22, did not have a Pennsylvania criminal history record check completed.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Submitted requests for background checks and clearances. 06/30/2022 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 9/30/21, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program specialist sent home form to be completed and returned by parent on 5/19/2022. 06/30/2022 Implemented
2380.113(a)Direct Service Worker #1, date of hire 1/26/22, had an initial physical examination completed 2/11/22. Direct Service Worker #3's most recent physical examination was completed 2/19/20.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.Program specialist requested physical from staff #1 upon discovery after reviewing new hire checklist. The physical was completed on 2/11/2022. Program specialist requested physical from staff #3 on 5/4/2022. They are scheduled to have their physical completed on 5/19/2022. 06/30/2022 Implemented
2380.113(c)(2)Direct Service Worker #1, date of hire 1/26/22, had an initial Tuberculin skin testing with negative results completed 2/14/22.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.Program specialist requested TB test upon discovery after reviewing new hire checklist. The TB test completed on 2/14/2022. 06/30/2022 Implemented
2380.36(b)Direct Service Worker #2, date of hire 3/16/22, did not have fire safety training.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program specialist played an OSHA certified fire safety training video to Staff #2 on 5/11/2022. A certificate of completion was printed and filed in their documentation folder. 06/30/2022 Implemented
SIN-00187187 Renewal 05/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1 had a physical examination completed on 9/03/2020, which did not include a hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program staff will send the physical form back to the individual 1 PCP to have him complete this section. Once the section is completed it will be reviewed by the program nurse and program specialist. Once completion of physical form is reviewed, the form filed in the individual ! file. Chart audits will be completed to make sure each participant physical forms are in compliance and complete. 05/07/2021 Implemented
SIN-00168635 Renewal 01/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(3)Program Specialist #1, date of hire 8/13/13, had a physical examination, dated 2/22/19; however, the physical examination did not address communicable diseases. This form only addresses communicable TB. Direct Services Worker #2, date of hire 9/5/16, had a physical examination, dated 1/11/19; however, the physical examination did not address communicable diseases. This form only addresses communicable TB. Direct Services Worker #3, date of hire 11/12/18, had a physical examination, dated 2/22/19; however, the physical examination did not address communicable diseases. This form only addresses communicable TB.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.The staff physical form has been updated with a statement that states the staff person is "free from communicable diseases, infections , and conditions. If a person does have a communicable disease "special precautions" must be specified and taken that will prevent the spread of disease to individuals. [According to the Program Specialist, the program specialist contacted the medical providers who performed the exams for the employees to complete a statement addressing communicable disease. The aforementioned updated physical examination form was provided to the agency pre-employment examination provider. Staff were trained on the new physical examination form to include what a communicable disease is and how it is spread. Newly hired staff persons have had a physical examination which addresses communicable disease. The form was reviewed by the program nurse, HR director and the program specialist. Upon completion of employee physical forms, a designated staff person shall audit the form to ensure all required information is present including addressing communicable disease. (DPOC by AES,HSLS on 1/22/20)] 01/10/2020 Implemented
SIN-00128546 Renewal 02/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Direct Service Worker #1, date of hire 5/1/17, had a Pennsylvania criminal history check submitted 6/1/17.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Program specialist and director will communicate with HR department and any new hires stipulating criminal background checks be completed with 5 working days after person's hire date. This is effective 2/5/2018. Please see supporting documentation sent to Human services Licensing Supervisor. [Correspondence letter was received from Western Pennsylvania School for Blind offering employment to candidate for Adult Program Aide contingent on clearances being provided. Immediately and upon hire, the Program Director or designee shall audit employees' criminal background checks to ensure timely completion. Documentation of audits shall be kept. (AS 2/8/18)] 02/06/2018 Implemented
2380.33(b)(4)Program Specialist #2 did not attend Individual's #1's annual ISP meeting held on 10/26/17.The program specialist shall be responsible for the following: Attending the ISP meetings.Program instructor attended individual #1 ISP meeting dated 10/26/17 due to program specialist attending a training. Program instructor holds an associates and 6 years experience in working with people who have disabilities. Moving forward program specialist or program director will attend and participate in all individuals ISP meetings. Next ISP meeting is scheduled for 2/8/18 which program specialist will attend. [Immediately and upon hire, the Program Director shall review the responsibilities of the program specialist position as per 2380.33(b)1-19 with the program specialist. Documentation of the trainings shall be kept. At least quarterly for 1 year, the Program Director shall review the ISP sign in sheets for all individuals' ISP meetings to ensure the program specialist attend the ISP meetings as required. (AS 2/8/18)] 02/06/2018 Implemented
2380.91(a)Individual #2, admission date 10/1/17, had initial fire safety training on 10/13/17.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.Individual number 2 was trained in fire safety including his means of communication dated 10/13/18. In between the time frame of those 13 days , individual was present 6 days of that time. Program specialist will instruct individuals mode of communication, fire safety, emergency procedures including evacuation , designated meeting place, and smoking policy on individuals first day at program and yearly after. [Immediately and continuing at least quarterly for 1 year, the Program Manager shall audit all individuals' fire safety training records to ensure all individuals are instructed in fire safety as required and training is completed timely and documentation of trainings are maintained. Documentation of audits shall be kept. (AS 2/8/18)] 02/06/2018 Implemented
2380.111(c)(5)Individual #1 had a Tuberculin skin test on 8/21/14 and then again on 8/20/17.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.Program specialist created a spread sheet on 2/5/2018 listing all dates of physical's and TB skin test . Program specialist gave spread sheet to program nurse to set reminders of when physicals and TB's are due.Program Nurse was retrained on when physicals/Tbs are due along with all area of physical form must be completed. Program specialist will also set scheduled reminders on the calendar at least 1 month prior to physicals and TB expiration.[Immediately and continuing at least quarterly for 1 year, the Program Manager shall audit the aforementioned tracking spread sheet and all individuals' current physical examinations including Tuberculin skin testing to ensure all individuals have physical examinations with all required information and completed, timely. Documentation of audits shall be kept. (AS 2/8/18)] 02/06/2018 Implemented
2380.111(c)(6)The physical examination for Individual #2, completed on 7/25/17, did not address communicable disease; therefore compliance could not be measured.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.Program specialist sent home WPSBC physical form to individuals parent for physician to complete unmarked areas. To prevent this in the future program specialist will require that all individuals physicals be completed on WPSBC physical for with all the required areas completed by physician. Program nurse will complete reviews of physicals upon receiving of them to make sure all areas are complete. Program specialist created a spread sheet on 2/5/2018 listing all dates of physical's and TB skin test . Program specialist gave spread sheet to program nurse to set reminders of when physicals and TB's are due.Program Nurse was retrained on when physicals/Tbs are due along with all area of physical form must be completed. [Immediately and continuing at least quarterly for 1 year, the Program Manager shall audit the aforementioned tracking spread sheet and all individuals' current physical examinations to ensure all individuals have physical examinations with all required information and completed, timely. Documentation of audits shall be kept. (AS 2/8/18)] 02/06/2018 Implemented
2380.111(c)(10)The physical examination for Individual #2, completed 7/25/17, did not include medical information pertinent to the diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.To prevent this in the future program specialist will require that all individuals physicals be completed on WPSBC physical for with all the required areas completed by physician. Program specialist created a spread sheet on 2/5/2018 listing all dates of physical's and TB skin test . Program specialist gave spread sheet to program nurse to set reminders of when physicals and TB's are due. [Immediately and continuing at least quarterly for 1 year, the Program Manager shall audit the aforementioned tracking spread sheet and all individuals' current physical examinations to ensure all individuals have physical examinations with all required information and completed, timely. Documentation of audits shall be kept. (AS 2/8/18)] 02/06/2018 Implemented
2380.181(f)The program specialist did not provide Individual #2's assessment, completed 10/23/17, to all plan team members, specifically the Companion Services provider.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Prior to the POC the program specialist sent the assessment to the parent/guardians and SC of each individual. Based on the POC the program specialist will also send individuals yearly assessment to the entire team no later then 30 days after assessment is completed. As of 2/5/18 program specialist has sent individuals yearly assessment to all paid supports listed in individuals ISP. [Immediately and upon hire, the Program Director shall review the responsibilities of the program specialist position as per 2380.33(b)1-19 with the program specialist. Documentation of the trainings shall be kept. At least quarterly for 1 year, the Program Director shall review the correspondence documentation showing the program specialist provided assessments for all individuals to all plan team members as required at least 30 days prior to the individuals' ISP meetings. (AS 2/8/18)] 02/06/2018 Implemented
2380.186(a)On 1/10/18, Program Specialist #1 and Individual #1 signed the ISP review, end dated 11/30/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.The Program Specialist reviewed the individuals progress review dated 11/30/2017. Program specialist will sign the review within 15 days of review and send to all team members. Program Specialist set reminders on calendar of required deadlines for all paperwork to be signed and sent to team on 2/5/18. [Immediately and upon hire, the Program Director shall review the responsibilities of the program specialist position as per 2380.33(b)1-19 with the program specialist. Documentation of the trainings shall be kept. At least quarterly for 1 year, the Program Director shall review the correspondence documentation showing the program specialist provided assessments for all individuals to all plan team members as required at least 30 days prior to the individuals' ISP meetings. (AS 2/8/18)] 02/06/2018 Implemented
2380.186(d)The program specialist did not provide Individual #3's ISP review, end dated 10/11/17 to all team members, specifically the in-home service provider. The program specialist did not provide Individual #4's ISP review, end dated 10/11/17 to all team members, specifically the in-home service provider.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.The program specialist has sent the quarterly progress and ISP review to the in home provider on 2/2/18. Program specialist will have all team members sign a declination form at the individuals annual ISP meeting stating their name, agency, and if they choose to accept or decline reviews. Program Specialist created a new declination for all team members to sign on 2/1/2018. Supporting documentation was sent to Human Services Licensing Supervisor.[Immediately and upon hire, the Program Director shall review the responsibilities of the program specialist position as per 2380.33(b)1-19 with the program specialist. Documentation of the trainings shall be kept. At least quarterly for 1 year, the Program Director shall review the correspondence documentation showing the program specialist provided ISP reviews for all individuals to all plan team members as required within 30 days after the ISP review meeting. (AS 2/8/18)] 02/06/2018 Implemented
2380.186(e)Program Specialist #1 did not notify all of Individual #3's plan team members of the option to decline the ISP review, specifically the in-home service provider. Program Specialist #1 did not notify all of Individual #4's plan team members of the option to decline the ISP review, specifically the in-home service provider.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Program specialist will have all team members sign a declination form at the individuals annual ISP meeting stating their name, agency, and if they choose to accept or decline reviews. Program Specialist created a new declination for all team members to sign on 2/1/2018. Supporting documentation was sent to Human Service Licensing Supervisor. [Immediately and upon hire, the Program Director shall review the responsibilities of the program specialist position as per 2380.33(b)1-19 with the program specialist. Documentation of the trainings shall be kept. Immediately, the Program Manager and Program Specialist shall audit all individuals' records including correspondence documentation, ISPs and invitation letters and immediately notify all plan team member for all individuals including Individual #3 and individual #3 of the option to decline the ISP review documentation. Correspondence documentation shall be maintained. At least quarterly for 1 year, the Program Director shall audit the correspondence documentation showing the program specialist notified all plan team members for all individuals of the option to decline. Documentation of all audits shall be kept. (AS 2/8/18)] 02/06/2018 Implemented
SIN-00107918 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(b)The ISP reviews completed 1/4/17, 10/4/16, 7/4/16 and 4/4/16 for Individual #1, Individual #2, Individual #3 and Individual #4 were not signed by the individuals.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The program specialist added a participant signature line on the quarterly progress reviews to be signed after the review from staff and participants. ISP reviews will continued to be reviewed every quarter and signed by program specialist and program participants. Any changes to the ISP will be sent to the Supports Coordinator. Chart audits will be completed on all participants files to ensure all documentation is completed and signed by program specialist and program participants. [Immediately, the ISP reviews completed 1/4/17, 10/4/16, 7/4/16 and 4/4/16 for Individual #1, Individual #2, Individual #3 and Individual #4 will be reviewed with and signed by the individuals. Immediately and at least quarterly thereafter for 1 year, a designated management staff person shall review all individuals' ISP reviews to ensure the program specialist and individual signed and dated the ISP review upon rive of the ISP. (AS 2/21/17)] 02/18/2017 Implemented
SIN-00090477 Renewal 02/23/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(b)The physical examination dated 9/25/15 for Individual #1 did not indicate from a licensed physician, certified nurse practitioner or certified physician's assistant that the individual is free from communicable disease or specific precautions that shall be taken if the individual has a serious communicable disease. The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.Program specialist will review each physical completed by the doctor to ensure all areas of physical are completed and no area is left incomplete. If an area is incomplete, program specialist will return to parents/guardians to have doctor complete incomplete areas. Staff will perform chart audits every 3 months to ensure all areas are complete. [Individual #1's physical examination completed 3/30/16 includes Individual #1 is free from communicable disease. Immediately, the program specialist will review all individuals¿ current physical examination to ensure all required information is present and will immediately obtain missing information. Upon completion and prior to entering in to each individual's record the program specialist will review all initial and annual physical examinations to ensure all required information is present and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 4/8/16)] 03/01/2016 Implemented
2380.181(d)The program specialist did not sign the assessment for Individual #1, dated 9/16/15. The program specialist did not sign the assessment for Individual #2, dated 7/2/15. The program specialist did not sign the assessment for Individual #3, dated 2/2/16. The program specialist shall sign and date the assessment.The Program Specialist reviewed participant assessments and added signature to each individuals assessment. Program specialist and or staff will complete chart audits to ensure all proper documents and documentation is complete at least once every 3 months.[Individual #1's assessment was signed by the program specialist on 3/20/2016. Individual #2's assessment was signed by the program specialist on 3/20/2016. Individual #3's assessment was signed by the program specialist on 2/23/16. Immediately, the program specialist will review and sign all individuals¿ current assessments that are not signed. Upon completion and prior to entering in to each individual's record the program specialist will complete and sign all initial and annual assessments. At least quarterly, the CEO or Program Director will review all individuals¿ assessments to ensure completion and that the Program Specialist has signed as required. Documentation of all reviews shall be kept. (AS 4/8/16)] 03/01/2016 Implemented
2380.186(a)The program specialist did not complete 3 month ISP reviews for Individual #1, admission date 9/19/14. The program specialist did not complete 3 month ISP reviews for Individual #2, admission date 6/10/14. The program specialist did not complete 3 month ISP reviews for Individual #3, admission date 9/13/11. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.A review of the ISP was completed every 2 months, but did not meet the regulations for review of progress made . The Program Specialist has created a quarterly review of the ISP and progress notes to be completed every 3 months and sent to the supports coordinator and parents if elected in the declination form. Declination form was created, sent home, and returned if parents wanted to receive the quarterly review. Staff will perform chart audits to ensure indivudal binders are complete with all necessary paper work and documentation at least one time every 3 months. [The program specialist will complete, sign and date ISP reviews as required. At least quarterly the CEO or designated management staff person will review all quarterly reviews to ensure the program specialist competed and sign and dated all individual's quarterly ISP reviews. Documentation of reviews of the quarterlies shall be kept. (AS 4/8/16)] 03/01/2016 Implemented
SIN-00075080 Renewal 02/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not posted on or by the telephone in the lounge area.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.Emergency phone number notifications have been placed at each telephone within the program. All staff were notified that these are present and should be followed in case of an emergency. Change has been corrected by Sara Watkins on March 2, 2015. [CEO or Designee will immediately check all telephones to ensure required telephone numbers are by each telephone and monitor at least monthly. (AS 3/23/15)] 03/07/2015 Implemented
2380.70(b)The first aid area did not have a blanket or pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.A blanket and pillow have been placed on the bed in the first aide room. All staff have been made aware that those items are to remain on the bed and are not to be removed. If used, they will be replaced immediately. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.91(a)Individual #1, date of admission September 19, 2014, was not instructed on general fire safety, 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 upon initial admission. Individual #1's initial fire safety is dated September 29, 2014.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.A fire safety policy has been created to ensure that all participants receive their fire safety training on the first day they attend the program. All staff have been instructed on this change. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.111(c)(3)Individuals #1, #2, and #4 physical examinations dated July 3, 2014, March 26, 2014 and August 20, 2014, respectively, did not include immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.A new physical form has been created to ensure that this requirement is addressed. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.111(c)(4)Individuals #1, #2, and #4 physical examinations dated July 3, 2014, March 26, 2014 and August 20, 2014 did not include vision and hearing screenings.The physical examination shall include: Vision and hearing screening, as recommended by the physician.A new physical form has been created to ensure that this requirement is addressed. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.111(c)(5)Individuals #1, #2 and #4 physical examinations dated July 3, 2014, March 26, 2014 and August 20, 2014, respectively, did not include Tuberculin skin testing.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.A new physical form has been created to ensure that this requirement is addressed. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.111(c)(6)Individuals #1, #2, and #4 physical examinations dated July 3, 2014, March 26, 2014 and August 20, 2014, respectively, did not include an area to address communicable diseases.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.A new physical form has been created to ensure that this requirement is addressed. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.111(c)(7)Individuals #1, #2 and #4 physical examinations dated July 3, 2014, March 26, 2014 and August 20, 2014, respectively, did not include an assessment of the individuals' health maintenance needs. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.A new physical form has been created to ensure that this requirement is addressed. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.111(c)(10)Individuals #1, #2 and #4 physcial examinations dated July 3, 2014, March 26, 2014 and August 20, 2014, respectively, did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A new physical form has been created to ensure that this requirement is addressed. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.113(a)The record for Staff #1, date of hire January 2, 2015, does not include a physical examination.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.A new substitute policy has been created. All substitutes will have completel physicals on file before working with the program. If a physical is not available, the substitute will only be permitted to work 4.5 days per 6 month period. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.113(c)(2)The record for Staff #1, date of hire January 2, 2015, does not include tuberculin skin testing with negative results.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.A new substitute policy has been created. All substitutes will have completel physicals on file before working with the program. If a physical is not available, the substitute will only be permitted to work 4.5 days per 6 month period. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.173(1)(ii)The records for Individuals #2 and #3 do not include 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.Though the question was present on the current emergency form, staff and parents have been instructed to ensure that all questions are answered and that there are no spaces left blank. All emergency forms have been updated and provide responses to all questions. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.173(1)(iii)The record for Individual #1 does not include the language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English.Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English.Though the question was present on the current emergency form, staff and parents have been instructed to ensure that all questions are answered and that there are no spaces left blank. All emergency forms have been updated and provide responses to all questions. Change has been corrected by Sara Watkins on March 2, 2015. 03/07/2015 Implemented
2380.181(e)(7)The assessments for Individuals #1, #2, #3 and #4 dated October 15, 2014, February 11, 2015, February 10, 2015 and July 1, 2014, respectively, did not include the individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The assessment has been corrected. An additional question regarding the individual's knowledge of the danger of heat sources and the ability to quickly move away from sources that exceed 120 degrees has been added. Change has been corrected by Sara Watkins on March 2, 2015.[CEO or Designee will review all individuals' current assessments to ensure they are assessed in the individuals knowledge of the danger of heat sources and ability to sense and move away quickley from heat sources. (AS 4/17/15)] 03/07/2015 Implemented
SIN-00148004 Renewal 01/10/2019 Compliant - Finalized