Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00191111 Renewal 08/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff #1 had a physical dated 3/6/2017 and the next physical was not completed until 4/27/2021 which exceeds the 2 year requirement.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.The program has an administrative assistant who is responsible for monthly checks of physical and TB due dates. An email is sent to the individual due for the physical and their supervisor 2 months prior to the due date. Supervisors will follow up with the employee to ensure completion within the needed time frame. As an additional reminder, communication from HR's tracking system (Vista) is also sent to supervisors. 09/09/2021 Implemented
2380.113(c)(2)Staff #1 had a TB test dated 3/8/2017 and the next TB test was not completed until 4/30/21 which exceeds the requirement of having a TB test every two years.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.The program has an administrative assistant who is responsible for monthly checks of physical and TB due dates. An email is sent to the individual due for the physical & TB and their supervisor 2 months prior to the due date. Supervisors will follow up with the employee to ensure completion within the needed time frame. As an additional reminder, communication from HR's tracking system (Vista) is also sent to supervisors. 09/09/2021 Implemented
SIN-00150984 Renewal 03/12/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)The area pertaining to health maintenance needs was left blank on Individual #1's annual physical form.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.Program specialists are aware that there are to be no blanks on the physical. In this instance, assistant director was covering in the absence of program specialist, and failed to fully review the annual physical once submitted. To prevent future oversight, program specialist will review physical upon admission, when being submitted for annual update, and during quarterly review. Incomplete physicals will be returned to family/provider with the request for the information to be completed as soon as possible. If there are blanks on a physical for a new participant, start date will be delayed. In the event a program specialist will be out for more than 2 weeks, a folder will be created so that all documentation submitted by consumers will be reviewed prior to being submitted into the client file. For this occurrence, the physical was sent back to the life sharing coordinator and provider, requesting the information be completed by 5/1/2019. If not completed, services will be suspended until information can be obtained. All other client physicals were reviewed and checked for completion. 05/01/2019 Implemented
2380.111(c)(8)The area pertaining to physical limitations was left blank on Individual #1's annual physical form.The physical examination shall include: Physical limitations of the individual.Program specialists are aware that there are to be no blanks on the physical. In this instance, assistant director was covering in the absence of program specialist, and failed to fully review the annual physical once submitted. To prevent future oversight, program specialist will review physical upon admission, when being submitted for annual update, and during quarterly review. Incomplete physicals will be returned to family/provider with the request for the information to be completed as soon as possible. If there are blanks on a physical for a new participant, start date will be delayed. In the event a program specialist will be out for more than 2 weeks, a folder will be created so that all documentation submitted by consumers will be reviewed prior to being submitted into the client file. For this occurrence, the physical was sent back to the life sharing coordinator and provider, requesting the information be completed by 5/1/2019. If not completed, services will be suspended until information can be obtained. All other client physicals were reviewed and checked for completion. 05/01/2019 Implemented
2380.111(c)(9)The area pertaining to allergies was left blank on Individual #1's annual physical form.The physical examination shall include: Allergies or contraindicated medication.Program specialists are aware that there are to be no blanks on the physical. In this instance, assistant director was covering in the absence of program specialist, and failed to fully review the annual physical once submitted. To prevent future oversight, program specialist will review physical upon admission, when being submitted for annual update, and during quarterly review. Incomplete physicals will be returned to family/provider with the request for the information to be completed as soon as possible. If there are blanks on a physical for a new participant, start date will be delayed. In the event a program specialist will be out for more than 2 weeks, a folder will be created so that all documentation submitted by consumers will be reviewed prior to being submitted into the client file. For this occurrence, the physical was sent back to the life sharing coordinator and provider, requesting the information be completed by 5/1/2019. If not completed, services will be suspended until information can be obtained. All other client physicals were reviewed and checked for completion. 05/01/2019 Implemented
2380.111(c)(10)Medical information pertinent to diagnosis and treatment in case of emergency was not addressed on Individual #1's annual physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program specialists are aware that there are to be no blanks on the physical. In this instance, assistant director was covering in the absence of program specialist, and failed to fully review the annual physical once submitted. To prevent future oversight, program specialist will review physical upon admission, when being submitted for annual update, and during quarterly review. Incomplete physicals will be returned to family/provider with the request for the information to be completed as soon as possible. If there are blanks on a physical for a new participant, start date will be delayed. In the event a program specialist will be out for more than 2 weeks, a folder will be created so that all documentation submitted by consumers will be reviewed prior to being submitted into the client file. For this occurrence, the physical was sent back to the life sharing coordinator and provider, requesting the information be completed by 5/1/2019. If not completed, services will be suspended until information can be obtained. All other client physicals were reviewed and checked for completion. 05/01/2019 Implemented
2380.111(c)(11)Any specific dietary needs or lack of was not addressed on Individual #1's annual physical form.The physical examination shall include: Special instructions for an individual's diet.Program specialists are aware that there are to be no blanks on the physical. In this instance, assistant director was covering in the absence of program specialist, and failed to fully review the annual physical once submitted. To prevent future oversight, program specialist will review physical upon admission, when being submitted for annual update, and during quarterly review. Incomplete physicals will be returned to family/provider with the request for the information to be completed as soon as possible. If there are blanks on a physical for a new participant, start date will be delayed. In the event a program specialist will be out for more than 2 weeks, a folder will be created so that all documentation submitted by consumers will be reviewed prior to being submitted into the client file. For this occurrence, the physical was sent back to the life sharing coordinator and provider, requesting the information be completed by 5/1/2019. If not completed, services will be suspended until information can be obtained. All other client physicals were reviewed and checked for completion. 05/01/2019 Implemented
2380.181(a)Individual #1's initial assessment was late. She was admitted to the program on 07-30-18 and her assessment was not completed until 10-22-18.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's assessment was due while Assistant Director was covering the Program Specialist position that was left vacant due to resignation. In the future, should the PS position be vacant for more than 2 weeks, a coverage plan will be implemented, and the person who is providing coverage in place of the PS will gather due dates and assure completion. All consumers documentation was reviewed and updated as needed. 04/12/2019 Implemented
SIN-00130510 Renewal 03/15/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)This section was blank on Individual #1's physical exam dated 2/23/2018.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.Program Specialists are aware that there are to be no blanks on individual physicals. It is their responsibility to check physicals when they are returned to the program. Moving forward, physicals that are incomplete will be returned to the parent/family/provider with the request that the missing information be completed as soon as possible. For this occurrence, the physical was returned to the provider on 3/15/2018 and was returned to the Life Program on 4/18/2018. 04/19/2018 Implemented
2380.111(c)(11)Individual #1 is diagnosed with Psychogenic Polydipsia and has to follow a drink schedule. The dietary instructions section on his physical exam dated 2/23/2018 was blank.The physical examination shall include: Special instructions for an individual's diet.Program Specialists are aware that there are to be no blanks on individual physicals. It is their responsibility to check physicals when they are returned to the program. Moving forward, physicals that are incomplete will be returned to the parent/family/provider with the request that the missing information be completed as soon as possible. For this occurrence, the physical was returned to the provider on 3/15/2018 and was returned to the Life Program on 4/18/2018. 04/19/2018 Implemented
2380.181(f)Individual #1 had his ISP meeting on 9/7/2017. His assessment was completed on 9/15/2017.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).Program leadership has created a document that will be used to indicate when assessments need to be updated by, so that there is adequate amount of time to get a copy sent to the individual¿s team, 30 days prior to the meeting. Program Specialists will be responsible for ensuring that assessments are completed and distributed by the expected due date. The document was implemented on 4/2/2018. 04/02/2018 Implemented
SIN-00111957 Renewal 05/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(8)The section pertaining to Physical Limitations was left blank on Individual #2's physical form.The physical examination shall include: Physical limitations of the individual.The physical was returned to the family for completion by physician. The physical limitations section was filled out, listing "none" as his physical limitations. This was returned to the program on 7/17/2017. 07/17/2017 Implemented
2380.111(c)(10)The section regarding info pertinent to medical diagnosis in case of emergency was left blank on Individuals #1's physical form and missing on Individual #3's physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A doctor's note from individual #1's physician, stating that in the event of an emergency, 911 should be called. This is now attached to the individuals physical. Regarding individual #3's physical, a new physical was obtained from the physician on 6/5/2017 with every section fully completed, which was placed in the individual's file. 07/14/2017 Implemented
2380.173(1)(ii)The section pertaining to eye color on Individual #3's file was left blank.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.The Program Specialists added this information to the individual's face sheet the day following licensing. An email was sent by program leadership reminding all Program Specialists that there are to be no blanks on an individuals face sheet. 05/19/2017 Implemented
2380.173(1)(iv)The section pertaining to religious affiliation was left blank on Individual #3's face sheet.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The religious affiliation was added to the individual's face sheet the day following licensing. An email was sent by program leadership to all Program Specialists reminding them that there are to be no blanks on the face sheet and that if something is unknown, they are to indicate that. 05/19/2017 Implemented
2380.181(e)(10)Individual #1's Assessment stated "see attached" for Lifetime Medical History, but nothing was attached. The other three Individuals' assessments simply did not include any lifetime medical history.The assessment must include the following information: A lifetime medical history.Program leadership attached Lifetime Medical History to Individual 1's assessment as well as the other participants in the program. Program leadership added the Lifetime Medical History to the assessment and distributed it to all Program Specialists so that in the future, the Lifetime Medical History will be attached to the assessment. This was distributed to all Program Specialists through email and they were instructed to begin using it immediately. 05/19/2017 Implemented
2380.181(f)There is no record that the asessment was sent to team members at least 30 days prior to the ISP meeting in any of the four Individual files.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).Program leadership sent an email to all Program Specialists that beginning immediately, all assessments must be emailed to Supports Coordinators 30 days prior to the ISP meeting. They were instructed to then print out the email and attach to the assessment as record that it was sent within the specified amount of time. 05/19/2017 Implemented
SIN-00091003 Renewal 04/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(e)The 2 garbage cans out the side exit do not have lids. There were also 2 bags of garbage on the ground near the cans.Trash outside the facility shall be kept in closed receptacles that prevent the penetration of insects and rodents.Garbage cans have been purchased by property owners and will be placed on the property of the Lehighton day program in place of the trash cans without lids. 05/02/2016 Implemented
2380.91(a)With the exception of new admissions in 2015 & 2016, all individuals (16 total) had fire safety training on 5/16/2014 & then not again until 6/18/2015, which surpasses 1 year.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.Director reviewed expectations of fire safety training for program individuals to not exceed one year in between trainings. Program Specialist will schedule trainings ahead of the due date for future trainings. 04/08/2016 Implemented
2380.113(a)Staff #1 had a physical on 11/19/2013. She did not have another physical exam until 1/21/2016, which surpasses 2 years.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 supervisor devised plan for tracking employee physicals and the timeframe for communicating to supervisors and employees when physicals are due. This spreadsheet will be monitored by Assistant Director and program supervisor will ensure employee physicals are completed by the due date. 04/08/2016 Implemented
2380.113(c)(2)Staff #1 had a TB test on 11/19/2013. The form doesn't have that this TB test was read by a professional nor the results of the TB test. Staff #1 did not have another TB test until 1/21/2016.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 supervisor devised plan for tracking employee physicals/tb tests and the timeframe for communicating to supervisors and employees when tests are due. This spreadsheet will be monitored by Assistant Director and program supervisor will ensure employee physicals/tb tests are completed by the due date. 04/08/2016 Implemented
2380.113(c)(3)The physical for staff #1 dated 1/21/2016 did not contain a statement that the staff member was free of 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.Staff #1 had a corrected physical form completed on 4/7/16 verifying that she is free of communicable diseases. 04/07/2016 Implemented
SIN-00073898 Renewal 03/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 did not have a TB test completed since 3/7/2013. 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 supervisors will suspend individuals from program if a current physical and/or mantoux shot is not submitted on time. Tracking system is put in place to ensure accurate tracking of physical and mantoux shot dates for both individuals and program staff. individual had a negative TB on 3/18/2015. This was not contained in the record at the time of inspection. CH 5/12/15. 04/06/2015 Implemented
2380.113(a)Staff #1 had a physical on 12/13/12 and not again until 1/5/2015.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 Director has implemented a program policy to reflect that any staff member who have lapsed in their physical due date will be suspended from work until annual physical is completed. 04/06/2015 Implemented
2380.128(a)Staff #1, #2, and #3 did not have completed initial Department's Medication Administration Trainings and are passing medications. A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.Program supervisor will reschedule these staff members for a current medication training, but in the meantime will distribute medication herself to individual's needing medication. 03/19/2015 Implemented
2380.173(9)Individual #2's ISP states that his meat must be cut-up due to a choking risk. Individual #2's Assessment does not state that his meat must be cut-up due to a risk of choking. Individual #2's ISP states that he is safe with heat sources except coffee pots. Individual #2's Assessment states that he is safe with heat sources and does not mention with the exception of coffee pots. Individual #3's ISP states that he may have 5 minutes of alone time in the bathroom at his day program. Individual #3's Assessment states that he may have 10 minutes of alone time in the bathroom at his day program. Individual # 4's ISP states that she requires assistance in traffic as she has been walking out in traffic and putting her hand out as a traffic cop would do. Individual #4's assessment states that she is independent and safe in traffic. Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.INDIVIDUALS SC WAS CONTACTED TO UPDATE ISP; HE DOES NOT NEED MEATS CUT UP.INDIVIDUALS SC WAS CONTACTED TO UPDATE ISP SINCE THE CONSUMER MADE PROGRESS ON heat source safety.INDIVIDUALS ASSESSMENT WAS UPDATED TO MATCH THE ISP, SPOKE TO THE SC AND THE TEAM FEELS 5min IS an adequate amount of alone time.SC WAS CONTACTED in regards to traffic safety AND THE ISP WAS UPDATED SINCE THE INDIVIDUAL HAS MADE PROGRESS WHEN OUT IN THE COMMUNITY. 04/01/2015 Implemented
SIN-00057331 Renewal 01/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(a)Staff # 1 did not receive full orientation to the facility prior working with the individuals. (a)  The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.Constance had her 2nd Day Orientation on December 24, 2013. A signed document that she received this training is now in her file. She also completed shadowing onsite, ISP reviews and an overview of program, activities and schedules. 01/20/2014 Implemented
2380.113(a)Staff #1 did not have a physical within 12 months prior to the start of her employment at the facility.(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 2 years thereafter.Constance received an updated physical and Mantoux on Janaury 14, 2014. 01/14/2014 Implemented
2380.186(c)(1)Individual #1 did not have an ISP Review within the three month time frame for the year 2013. (c)  The ISP review must include the following: (1)  A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.A meeting will be held every 3 months as scheduled. The supports coordinators are not mandated to attend these meetings, so if they cannot attend, we will continue to have the meeting. A review of the meeting will be sent to the supports coordinators so they will understand what was discussed at the meeting. Therefore, we will not run into rescheduling past 3 months for each quarterly. 01/23/2014 Implemented
SIN-00043886 Renewal 01/30/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Staff 1 has hired on 1/3/11 and has a total of 18.5 training hours.(c)  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.HR will send quarterly staff training reports to Life Director for review. If a staff member is short on trainings, necesary trainings will be assigned to be in compliance. An online training system to track staff trainings will begin July 1, 2013. The Life Program is in the process of hiring a training coordinator to oversee and track staff's trainings. -partially implemented 3/11/13 CH 02/01/2013 Implemented
2380.183(4)Individual 1 is assessed as requiring no direct supervision at the program. The Individual Support Plan for Individual 1 does not include information on supervision needs for the Adult Training Facility. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: (4)  A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.The Individual Support Plan was updated by the Support Coordinator, and the Assessment Plan was updated by the Program Specialist. The plans now match for supervision: Client is not unsupervised at Day Program with the exception of bathroom privileges or refueling for gas up to 15 minutes. Client is up to dte with his Physical and Mantoux. -Fully Implemented 3/11/13 CH 02/01/2013 Implemented
SIN-00228795 Renewal 08/01/2023 Compliant - Finalized
SIN-00209703 Renewal 08/16/2022 Compliant - Finalized
SIN-00172157 Renewal 03/10/2020 Compliant - Finalized