Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241744 Renewal 03/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical examination, completed 3/29/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination, completed 11/15/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.As you will see with the attached documentation, I have corrected the physical examinations for both Individual # 1 and Individual # 2; I have included on each of the physical exams the medical information pertinent to diagnosis and treatment in case of an emergency for Individual #1 & Individual #2. I have also updated our "INDIVIDUAL PHYSICAL EXAMINATION CHECKLIST" to include the statement: Section for "in case of emergency" is completed (means any emergency medical intervention that maybe required in response to an acute or chronic medical condition; this section is not for emergency contact information) This document is also attached. This new form has been put in place to be used immediately (as of April 1, 2024). Each time an Individual's physical is submitted into the program our nurse will review the physical using the INDIVIDUAL PHYSICAL EXAMINATION CHECKLIST 2 to ensure all fields are completed correctly. If there is not a nurse present, then the director will be responsible to ensure the physical is acceptable using the new CHECKLIST. At this time the program has hired a new nurse and once they have completed the 6100 Trainings this director will review with them the expectations the state has in place for an acceptable Physical Examination for Individuals and how to complete the INDIVIDUAL PHYSICAL EXAMINATION CHECKLIST 2 form. 04/14/2024 Implemented
SIN-00204437 Renewal 05/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(u)Individual #1 was informed and explained individual rights on 7/2/21, Individual #2 and Individual #3 were informed and explained individual rights on 1/20/22, and Individual #4 was informed and explained individual rights on 8/24/21; however, the rights document did not include all the individual rights as per 2380.21(a) through 2380.21(v). The following rights were not included: 2380.21(c), an individual may not be reprimanded, punished, or retaliated against for exercising the individual's rights; 2380.21(d), 2380.21(e), 2380.21(g), related to court's written orders, court appointed legal guardians and designated persons; 2380.21(h), 2380.21(l), 2380.21(n). 2380.21(o) related to discrimination, choice, risks, privacy, access, and security and 2380.21(r), individual's rights shall be exercised so that another individual's rights are not violated.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Indiv #1, 2, 3 & 4 along with other participants of this CLC CPS facility participated in retraining on ¿Rights and Responsibilities¿ from the 2020 booklet along with the 2380¿s supplement page. Booklets and the supplement page for each participant were used and continue to be available to all. The Booklet is used to provide visual representations of topic while Program Specialist (PC & MN) and/or Director (AW) lead conversation identifying and detailing Individual Rights, the 2380 supplement page ensures that all 2380.21 listings are addressed, explained and discussed. Retraining completed with Individual #1,2,3 & 4 on 5-5-22, 5-6-22 and 5-10-22 06/11/2022 Implemented
SIN-00164481 Renewal 10/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(6)Individual #1's assessment completed 9/20/19 did not include the individual's ability to safely use or avoid poisonous materials. This section was blank.The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Staff completed the assessment and reviewed this individuals assessment to be sure everything was documented. Administrative staff at the CPS reviewed all assessments to ensure all assessments were completed. From this year forward all assessments will be reviewed by CPS administration quarterly to ensure all questions are answered to their fullest extent. 10/17/2019 Implemented
SIN-00103025 Renewal 10/31/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.11The first floor of the building is currently the only area that is licensed under the certificate of compliance. There are four rooms on the second floor of the building that are not licensed under the current certificate of compliance that are being used as program areas for five individual. The requirements in Chapter 20 (relating to licensure or approval of facilities and agencies) shall be met.Community Living Care, Inc. completed the self-inspection and declaration tool for our facility in Greensburg in February 2016. Upon completion of these documents we held them believing we were to present them to the licensors during our annual on-site licensing inspection. During our annual on-site inspection on October 31, 2016 we were made aware that the requirement is to submit the self-inspection and declaration tool to ODP once the documents are completed. This realization prompted us to immediately submit the completed self-inspection and declaration tool to ODP via email. Submitted on 10/31/16. As a result of this realization community living care, Inc. has implemented the following procedure. Any self-inspection and declaration tool will be completed by the program director for the affected program. Once the tool is complete, the program director will meet with the chief operating officer to review the documents. At this time; a discussion will occur and assignment made for the program director to submit the documents to the appropriate oversight/licensing entity within a specific period of time. Follow-up reporting to the COO will also be clearly defined.[Prior to relocating individuals or utilizing unlicensed areas, the CEO shall complete and submit a self inspection and other required documents to the department and receive an updated Certificate of Compliance as required as per Pennsylvania Code Title 55 Chapter 20. (AS 11/23/16)] 11/13/2016 Implemented
2380.181(e)(7)The assessment dated 9/8/16 for Individual #1 did not include 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. This section was left blank. 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 Program Specialist, Penny Crowe, contacted the individual's guardian/parent to determine if the individual would know the danger of heat sources and their ability to sense and move away quickly from heat sources that exceed 120* and are not insulated. Through email correspondence the individual's mother stated that he would NOT be able to recognize heat sources as a potential danger but that "YES" he would pull away or remove himself from the heat source. The Program Specialist, Penny Crowe, completed the assessment and included the email correspondence in the individual's Intake section of his permanent record book. In the future the Program Director will review all new individual's assessments to ensure documents are complete. [Immediately, the program specialist and program director shall review the requirements of assessment as per 2380.(e)(1)-14). Documentation of reviews shall be kept. (AS 11/23/16)] 11/13/2016 Implemented
SIN-00077885 Renewal 10/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)The initial assessment for Individual #1, date of admission 10/21/2014, was completed on 04/17/2015.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.The Plan of Correction for Reg. 2380 [181](a): Eric Noel, COO, conducted a training with Megan Nasky (Program Specialist), Penny Crowe (Program Specialist) and Amy Weimann (ATF Director) on 11/03/15 which reviewed how an assessment is required 60 calendar days (not actual attendance days) after the admission to the facility and an updated assessment is required annually thereafter. The Program Specialists and the Program Director will review admission and assessment dates from now on to ensure compliance with this regulation. 11/06/2015 Implemented
2380.186(a)The program specialist did not complete any ISP reviews for Individual #1, date of admission 10/21/2014.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 Plan of Correction for Reg. 2380 [186](a): Eric Noel, COO, conducted a training on 11/03/15 with Megan Nasky (Program Specialist), Penny Crowe (Program Specialist) and Amy Weimann (ATF Director) to review the regulation that states services for an individual must be reviewed at least every three months by the Program Specialist. We also went over that the three month period starts from the date of the last review and therefore, four reviews will be conducted in the course of a year. We also went over that calendar days will dictate the completion of a three month review not actual attendance days. [COO will audit the 3 month ISP reviews completed by the PS for at least 6 months to ensure timeliness of completion. Documentation of the audits will be maintained by the COO. (AS 12/4/15)] 11/06/2015 Implemented
SIN-00060990 Renewal 10/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #1's most recent assessments were completed on 11/16/12 and 12/9/13. The most recent assessment for Individual #2 was completed on 9/20/13.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.PLAN OF CORRECTION For IDD Inspection on 10/06/2014 As part of our Plan of Correction, Eric Noel, COO, conducted a training on 10/14/2014 with all parties involved (the ATF Director and two Program Specialists) with individuals¿ assessments. The training included reviewing the regulation 181 (a) that states a written assessment needs to be completed or updated within one year from the date of the previous assessment. The Director and both Program Specialists are aware that they are responsible for ensuring the assessments completion within the years time. 10/19/2014 Implemented
SIN-00051542 Renewal 06/26/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.186(d)ISP review documentation for Individual #1 was provided to the supports coordinator and plan team members prior to being reviewed with the individual. The review conducted on 2/5/13 was provided to the SC and plan team members on 1/17/13. The review conducted on 11/1/12 was provided to the SC and plan team members on 10/18/12, and the review conducted on 7/30/12 was provided to the SC and plan team members on 7/18/12.(d)  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 meetingALTHOUGH IT MAY APPEAR TO OTHERS THAT THE ISP REVIEW DOCUMENTATION WAS SENT TO THE TEAM BEFORE IT WAS REVIEWED WITH THE INDIVIDUAL (BECAUSE THE REPORT WAS DATED FOR THE DATE IT WAS DUE/PRINTED, NOT THE DATE IT WAS REVIEWED WITH AND SIGNED BY, THE INDIVIDUAL) THE DOCUMENTATION/ REPORTS WERE ACTUALLY SENT ONLY AFTER REVIEWING WITH THE INDIVIDUAL. THE PROGRAM SPECIALISTS WILL NO LONGER TYPE THE DATE THE REPORT IS COMPLETED ON THE COMPUTER, WE WILL HAND WRITE THE DATE THE REPORT IS COMPLETED, WHICH ONLY OCCURS, AFTER REVIEWING WITH AND OBTAINING A SIGNATURE FROM, THE INDIVIDUAL. TRAINING WAS HELD ON 07/30/2013, BY THE DIRECTOR OF THE ATF, WITH ALL PROGRAM SPECIALISTS TO REVIEW THE PLAN OF CORRECTION. THE DIRECTOR WILL ALSO BE RESPONSIBLE FOR ENSURING THE IMPLEMENTATION OF THE PLAN OF CORRECTION. 08/08/2013 Implemented
SIN-00223170 Renewal 04/20/2023 Compliant - Finalized
SIN-00187048 Renewal 05/07/2021 Compliant - Finalized
SIN-00143994 Renewal 10/19/2018 Compliant - Finalized
SIN-00123826 Renewal 10/30/2017 Compliant - Finalized