Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230729 Renewal 09/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)An unlocked closet in the smaller program room contained cleaning chemicals, such as Lysol spray and Enzym D cleaner.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.A sign was put on the door stating this door must be locked at all times. We implemented a staff person to check the door each morning at the start of her shift. 10/06/2023 Implemented
2380.111(c)(10)Individual 1's most recent annual physical exam did not contain information pertinent to diagnosis in case of emergency. Individual 2's 6/13/23 physical also does not contain information pertinent to diagnosis in case of emergency, nor did Individual 3's 10/7/22 physical.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.CATCH contacted the Caregivers for individual #1 and Individual #3 , we also contacted the residential contact for Individual #2, and reviewed the section "information pertinent to diagnosis and treatment in case of an emergency" on the identified physicals. We agreed to pertinent information and it was added to Individual #1, #2, and #3 physicals, sent to SCO, and placed in file. CATCH also reviewed all other physicals of participants in the program to ensure "info pertinent to diagnosis" sections of the physicals was completed. 11/08/2023 Implemented
2380.176(a)Personal client records, such as physical records, were stored unlocked in an unsecured shred pile.Individual records shall be kept locked when they are unattended.CATCH locks up shredding material in a cabinet that is located next to the shredder. 09/22/2023 Implemented
SIN-00211304 Renewal 09/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(c)Staff #2 Pa criminal history record check was completed more than 1 year prior to hire, staff was hired on 07/6/2022 and clearance was submitted 06/16/2021 The date of hire for staff 1 was August 1, 2022. Staff 1 criminal history was conducted on September 3, 2021. This is more than a year prior to their hire date.Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire.Staff # 2 had a criminal clearance completed on 9/14/2022 09/26/2022 Implemented
2380.113(a)The agency did not provide a Staff physical examination form for Staff #2 who was hired on 07/06/2022.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.CATCH HR Department was informed on 9/14/2022 of the physical policy/requirement for any new hires or hire from a different CATCH program to have a physical completed prior to transferring to CATCH CPS program 09/26/2022 Implemented
2380.36(b)The agency failed to train staff annually by a fire safety expert in the specified areas. (ALL STAFF)Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).CATCH is in compliance as of 12/2021 through this current year. Next Fire Safety Training is scheduled for October 21, 2022 09/26/2022 Implemented
SIN-00193488 Renewal 09/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Smart touch and various spray cleaners including Lysol wipes were located in the professional development room and a spray cleaner was located on the bottom drawer of a cabinet in the smaller activity room. Both of the aforementioned locations were accessible to individuals.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The cleaning spray bottle, the Lysol wipes, and smart touch spray cleaners were immediately put in a locked cabinet. The supported employment staff locked their spray cleaners and Lysol wipes in the office closet and the DSP staff lock the spray cleaners in the designated locked cabinet in the large program room. 10/05/2021 Implemented
2380.70(d)There were no tweezers or antiseptics in the first aid kit located in the sensory room.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.Antiseptic ointment and tweezers were immediately added to the first aid kit that did not have the required items. 10/05/2021 Implemented
2380.111(a)The physical exam conducted on 9/24/20 for Individual 1 did not contain the following sections that are required of a physical exam: Communicable Disease Precautions, Special Diet Instructions, Information Pertinent to Diagnosis in Case of Emergency. This information was not verified at admission.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Director, reviewed all participants physicals to verify no other exam was missing Communicable Disease Precautions, Special Diet Instructions, and Information pertinent to diagnosis in case of emergency. Program Director indicated that two of the areas cited were in fact followed up on with individual 1's PCP via fax on 2/16. Those two areas were Special diet instructions and Information pertinent to Diagnosis in case of emergency. Ind. 1 was admitted on 3/1 and this information was verified on 2/16. This documentation was included with ind. 1's physical upon submission to licensing team and resubmitted with this POC. IDD Director, sent a letter to Individual 1's PCP office requesting verification that Individual is free from Communicable disease. 10/07/2021 Implemented
2380.36(a)Fire safety training was not completed prior to working with individuals for staff 1 who was hired on 9/8/2021 and staff 2 who was hired on 8/30/2021. The training was held on 9/23/2021.Program specialists and direct service workers shall be trained before working with individuals in 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.Program Director developed a new tracking/training document specifically for new hires. Staff 1 and Staff 2 signed this form to ensure required fire safety training was documented for our records. 10/07/2021 Implemented
2380.37(a)The annual and applicable orientation training records for staff 1, 2 and 3 did not contain the source of the trainings. The Sign in sheets contained the staff participant initials in checklist format but did not include the trainer or training organization source's identification. In addition, the source of the initial general fire safety training for staff 1 and 2 could not be verified at inspection.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Program Director added the Source of Training to the training documentation form. All staff's training records were updated with this form to now include the source of the training. Staff 1, 2, and 3 revised records were submitted with this POC. 10/07/2021 Implemented
SIN-00120548 Renewal 09/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.183(4)Individual # 1 and Individual # 2 have direct supervision noted in their respective ISP. Neither individuals have a protocal and schedule outlining time w/o direct supervision.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: 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.Both individual #1 and #2 current assessments do not state that the individual may be without direct supervision. Both individuals' plans do not include an expected outcome which requires the achievement of a higher level of independence. The Program Specialist for individuals #1 and #2 added a protocol regarding supervision to their assessments. (See attachments) For the purpose of this protocol, "without direct supervision" will be defined as "turning your back to someone" or "without face to face contact". These protocols will be emailed to their Support Coordinators with a request to complete a general update in order to include it in their plans. Copies of all emails and documentation will be kept in each individual's file. However, we do not control if or when it will be added to his plan. Starting October 2, 2017, all assessments for individuals receiving services under the 2380 regulations will have a protocol regarding supervision included in their assessment. 11/01/2017 Implemented
SIN-00098043 Renewal 07/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.67(a)In the large activity room there was a chair without arms that had a tear in the seat. There were loose handles on a steel cabinet near room #10. Furniture and equipment shall be nonhazardous, clean and sturdy.All furniture and equipment was inspected. The chair with the tear in the vinyl was repaired. (see photo attachment 3 ) The cabinet with the broken handle was replaced. (see photo attachment 4) The Program Director or designee will inspect all furniture and equipment on a weekly basis to ensure that all furniture and equipment is non-hazardous, clean and sturdy. If any furniture or equipment is hazardous or is not sturdy, it will be removed from the program area and CATCH's maintenance will be contacted within one business day to determine if it can be repaired. If the furniture or equipment can not be repaired, it will be replaced. 08/19/2016 Implemented
2380.113(a)Staff #1's current physical exam was completed on 1/26/16 and the previous one was dated 6/4/13.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.Up until now, tracking the staff's physicals for the ID Division has been the responsibility of the ID Division Director and/or Day Program Director. To ensure this violation does not re-occur, this responsibility has been delegated to our Human Resources department. CATCH's HR department has an existing protocol to track all agency wide staff's physicals. The ID Division Director made a chart of the dates of all the staff's physicals. The chart was given to our HR department who put the dates in an existing employee data base. HR will send a letter and blank physical form to each staff 1 1/2 month prior to his/her physical due date. (see attached 1 & 2))[Quality Assurance or Program Designee will complete a quarterly audit of staff records to ensure the database is accurate and staff are completing the test prior to it's expiration DD 9.12.16] 08/22/2016 Implemented
2380.113(c)(2)Staff #1's current TB test is dated 1/22/16 and the previous test was completed on 6/6/13. 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.Up until now, tracking the staff's TB test for the ID Division has been the responsibility of the ID Division Director and/or Day Program Director. To ensure this violation does not re-occur, this responsibility has been delegated to our Human Resources department. CATCH's HR department has an existing protocol to track all agency wide staff's TB tests. The ID Division Director made a chart of the dates of all the staff's TB tests. The chart was given to our HR department who put the dates in an existing employee data base. HR will send a letter and blank physical form to each staff 1 1/2 month prior to his/her TB test due date. (see attached 1 & 2)[Quality Assurance or Program Designee will complete a quarterly audit of staff records to ensure the database is accurate and staff are completing the test prior to it's expiration DD 9.12.16] 08/22/2016 Implemented
SIN-00074663 Renewal 02/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(c)Food items were stored in a closet with "Go Jo" hand soap. Container label states "if swallowed call poison control". Not all of the participants of the program have been assessed to safely handle poisonous material.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Go Jo soap was immediately removed. It is now stored in a locked closet that does not contain food items. The provider agency trainer will conduct an inservice to all staff regarding the importance of keeping poisonous materials locked at all times to ensure the safety of the participants of the program within 30 days of receipt of this plan of correction. In addition, the Program Director or Designee will conduct weekly rounds of the program to ensure that all poisonous material is locked and inaccessible to the participants, starting within 15 days of receip of this plan of correction. [SW 5.15.15] 02/24/2015 Implemented
2380.58(b)The arts and crafts area has a fire extinguisher that has a loose braket attached to the wall.Floors, walls, ceilings and other surfaces shall be free of hazards.The fire extinguisher was moved to a different wall with a more secure bracket. The original wall was repaired. The Program Director of designee will conduct weekly rounds of the facility to ensure that the fire extinguisher is in a secure to the wall at all times. 02/27/2015 Implemented
2380.67(a)The main day program contained three handled chairs with fabric split on the chair's back and additional two chairs with tears to the seats. The arts and crafts area had three chairs with multiple tears to the seats.Furniture and equipment shall be nonhazardous, clean and sturdy.All furniture was inspected. New chairs were ordered on May 1, 2015. The Program Director or designee will conduct weekly rounds of the facility to ensure that all furniture and equipment is clean, sturdy and in good repair. 06/03/2015 Implemented
2380.111(c)(5)Individual # 1's physical examination, dated 3/12/14, did not list a current Tuberculin skin test.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.Individual #1 had a TB test administered on 4/3/2015. It was read as negative on 4/6/2015. The Program Director or designee will audit all of the participants physical examination records to ensure that all participants have received a Tuberculin skin test every two years and if not, will schedule an appointment to obtain the Tuberculin test as soon as possible. The audit will be conducted within 30 days of receipt of this plan of correction. In the future, the Program Supports Specialist will review all annual physical examinations to ensure that all of the required elements of the regulations are included in the examination. 04/06/2015 Implemented
SIN-00149533 Renewal 02/05/2019 Compliant - Finalized
SIN-00060121 Renewal 02/27/2014 Compliant - Finalized
SIN-00047563 Renewal 03/22/2013 Compliant - Finalized