Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216743 Renewal 01/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(13)(ii)Individual #1 and Individual #2's annual assessments did not include progress and growth over the last 365 calendar days in motor and communication skills.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The assessments that were completed on Individual #1 and #2 were completed on an old template and not the revised one that would of included the individuals progress ,growth and current level in motor and communication skills over the last 365 days. The provider will remove the old template to reassure compliance in this area within our assessment. 01/16/2023 Implemented
2380.181(e)(13)(iii)Individual #1 and Individual #2's annual assessments did not include progress and growth over the last 365 calendar days in Personal adjustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The assessments that were completed on Individual #1 and #2 were completed on an old template and not the revised one that would of included the individuals progress and current level in personal adjustment over the last 365 days. The provider will remove the old template to reassure compliance in this area within our assessment. 01/16/2023 Implemented
2380.181(e)(13)(iv)Individual #1 and Individual #2's annual assessments did not include progress and growth over the last 365 calendar days in socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The assessments that were completed on Individual #1 and #2 were completed on an old template and not the revised one that would of included the individuals progress , and current level in Socialization skills over the last 365 days. The provider will remove the old template to reassure compliance in this area within our assessment. 01/16/2023 Implemented
2380.181(e)(13)(v)Individual #1 and Individual #2's annual assessments did not include progress and growth over the last 365 calendar days in recreation.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The assessments that were completed on Individual #1 and #2 were completed on an old template and not the revised one that would of included the individuals progress , and current level in Recreation over the last 365 days. The provider will remove the old template to reassure compliance in this area within our assessment. 01/16/2023 Implemented
2380.181(e)(13)(vi)Individual #1 and Individual #2's annual assessments did not include progress and growth over the last 365 calendar days in community integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The assessments that were completed on Individual #1 and #2 were completed on an old template and not the revised one that would of included the individuals progress , and current level in community integration over the last 365 days. The provider will remove the old template to reassure compliance in this area within our assessment. 01/16/2023 Implemented
SIN-00124573 Renewal 11/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)A cabinet containing various poisons was left unlocked/open in a room where several consumers were congregated.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.POC 2380.53 A- Citation- Poisonous material shall be kept locked or made inaccessible to individual when not in use. Specific Findings of Non-compliance: A cabinet containing various poisons was left unlocked /open in a room where several consumers were congregating. Corrective Action: To implement a process to reinforce our policy for compliance of regulation 2380.53A. Plan to Prevent Recurrence: The provider will implement the following process to prevent reoccurrence of this specific citation. 1 .The current Program Policy that references 2380.53 (A), storage of poisonous materials identifies the protocol that is in place for compliance of this regulation. The policy identifies that all newly hired staff, receive orientation that mandates that the cabinets are not to be left unlocked for any reason at any time. If staff is to open this cabinet to obtain any item, they are to be within arms reach whenever the cabinet is unlocked. ¿Responsible persons: Program Director, Program Manager and Site Supervisors 2. 01/05/2018- Currently in-service training is completed upon hire and annually thereafter. Current policy has been revised to have quarterly in-service training along with the revision of the ATF 2380 scheduled in-servicing training beginning 01-09-2018. Responsible Persons: Program Director, Program Manager and Site Supervisors. 3. 11/10/2017-Following your on-site visit, staff were re-inserviced in toxic materials and storage. A toxic inspection of all training areas was completed, unannounced, by our site supervisor. These unannounced inspections will continue on a monthly basis, performed by our site supervisors or program manager. These inspection findings will be entered as part of our Vocational Safety Meeting. Responsible Persons: Program Director, Program Manager and Site Supervisors 4. 01-05-2017- Any findings from these inspections that would violate this regulation will result in disciplinary action deemed appropriate by our facility management to the staff involved. The two staff that was responsible for the unlocked cabinet were given a first and final warning that can lead to termination if this should occur again. All other program staff has been made aware of this procedure. Responsible Persons: Program Director, Program Manager and Site Supervisors Supporting Documentation: Policy- Toxic Storage 2018 -ATF in-service training calendar ATF- Staff Orientation 11-10-2017- Monthly Toxic Inspection Form 11-10-2017 Toxic review in-service sign in sheet 01/05/2018 Implemented
2380.111(c)(3)Individual #1 did not have the DT immunization.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.POC 55 PA Code Chapter 2380.111(c)(3) - Citation The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Specific Findings of Non-compliance: Individual #1 did not have the DT immunizations. Corrective Action: To implement a process to reinforce our policy for compliance of regulation 55 PA Code Chapter 2380.111(c) (3) Plan to Prevent Recurrence: The provider will implement the following process to prevent reoccurrence of this specific citation. 1 .The Admissions Program Policy that references 55 PA Code Chapter 2380.111(c)(3), This policy was revised as of 11-10-2017 to state an individual will not be able to participate in the Adult Training Facility Program without required immunizations. Upon potential admission, historical information will be reviewed to confirm if DT immunization and other required immunizations were received and included as part of the record. Responsible Persons: Vocational Program Director, ICF-ID Program Director, Vocational and ICF-ID nursing staff. 2. 11-10-2017 to Current, all individual files were reviewed. The Adult Training Facility nursing staff created an excel spread sheet, which details the vaccination dates for all individuals regarding the required 10 years TDAP immunization. This excel spread sheet will be reviewed quarterly by both the Adult Training Facility nursing and ICF-ID nursing for compliance. Responsible Persons: Vocational Program Director, ICF-ID Program Director, Vocational and ICF-ID nursing staff. 3. 01-05-2018- ICF-ID nursing schedules the individuals annual physical and reviews the medical record/excel sheet for compliance of immunizations. The Adult Training Facility nursing staff will also review all immunization requirements for compliance. If the individual is not given the required DT within the 10 year repeat cycle, the individual will not attend program until vaccination is completed. Responsible Persons: Vocational Program Director, ICF-ID Program Director, Vocational and ICF-ID nursing staff. Supporting Documentation: Policy- Admissions - Immunizations Spread sheet of all individual files immunization needs Individual #1 received her DT shot on 11/13/2017. Individual did not attend program on 11/10 ( Friday). 01/05/2018 Implemented
2380.111(c)(3)Individual #2's date of admission was 09-12-16. He received his TDaP on 10-10-16. TDap is required upon admission.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.POC 55 PA Code Chapter 2380.111(c)(3) - Citation The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Specific Findings of Non-compliance: Individual #2's date of admission was 09-12-16. He received his TDAP on 10-10-16. TDAP is required upon admission. Corrective Action: To implement a process to reinforce our policy for compliance of regulation 55 PA Code Chapter 2380.111(c) (3) Plan to Prevent Recurrence: The provider will implement the following process to prevent reoccurrence of this specific citation. 1 .The Admissions Program Policy that references 55 PA Code Chapter 2380.111(c)(3), This policy was revised as of 11-10-2017 to state an individual will not be able to participate in the Adult Training Facility Program without required immunizations. Upon potential admission, historical information will be reviewed to confirm if TDAP immunization and other required immunizations were received and included as part of the record. Responsible Persons: Vocational Program Director, ICF-ID Program Director, Vocational and ICF-ID nursing staff. 2. 11-10-2017 to Current, all individual files were reviewed. The Adult Training Facility nursing staff created an excel spread sheet, which details the vaccination dates for all individuals regarding the required 10 years TDAP immunization. This excel spread sheet will be reviewed quarterly by both the Adult Training Facility nursing and ICF-ID nursing for compliance. Responsible Persons: Vocational Program Director, ICF-ID Program Director, Vocational and ICF-ID nursing staff. 3. 01-05-2018- ICF-ID nursing schedules the individuals annual physical and reviews the medical record/excel sheet for compliance of immunizations. The Adult Training Facility nursing staff will also review all immunization requirements for compliance. If the individual is not given the required DT within the 10 year repeat cycle, the individual will not attend program until vaccination is completed. Responsible Persons: Vocational Program Director, ICF-ID Program Director, Vocational and ICF-ID nursing staff. Supporting Documentation: Policy- Admissions - Immunizations Spread sheet of all individual files immunization needs 01/05/2018 Implemented
SIN-00235599 Renewal 01/11/2024 Compliant - Finalized
SIN-00197748 Renewal 01/27/2022 Compliant - Finalized
SIN-00162264 Renewal 08/22/2019 Compliant - Finalized
SIN-00143082 Renewal 09/25/2018 Compliant - Finalized
SIN-00100215 Renewal 10/06/2016 Compliant - Finalized
SIN-00082675 Renewal 09/16/2015 Compliant - Finalized
SIN-00050478 Renewal 06/27/2013 Compliant - Finalized
SIN-00050479 Renewal 06/27/2013 Compliant - Finalized