Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238049 Renewal 01/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.72(a)Exterior exits from the main corridor and exterior exits from program rooms attached to that corridor let out onto paths that have not been cleared of ice and snow, creating a fall hazard.Outside walkways shall be free from ice, snow, obstructions and other hazards.The landscaper who is responsible for snow removal addressed the issue same day and cleared the paths of snow and put down rock salt. A shovel and rock salt was left on premise for Community Center custodian and Delta maintenance team to maintain throughout the day. 01/19/2024 Implemented
2380.72(b)Just outside the Room 5 Exit in Wing B, the roof has a large hole in the plywood due to what appears to be rotting wood. Also, the wood framing appears shredded and is in need of repairs.The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.The carport was assessed on 1/19/24 and determined needed to be demolished. Car port was demolished on 2/12/24 (Attachment #9). 02/12/2024 Implemented
2380.82The Exit Door in Room 5 of Wing B took two arms and full body weight to push open. It also took two arms to pull to get closed.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Maintenance completed a temporary fix to ensure the door could function properly on 1/29/24 and the door contractor come out and repaired the door on 2/7/24 (Attachment #8). 02/09/2024 Implemented
2380.91(c)There was no documentation that Individual #1 had annual fire safety training completed within the last year.A written record of firesafety training, including the content of the training and individuals attending, shall be kept.Individual #1 received Annual Fire Safety Training on 1/19/2024 (Attachment #8). Training was completed using a video, ¿Plan to Get Out Alive.¿ Video explains how quickly fires can begin, what to do in the event of a fire, following an escape route, fire extinguishers, smoke detectors, etc. 02/18/2024 Implemented
2380.21(v)The following individuals did not have signed rights statements from within the last year: - Individual #1 - Individual #2 - Individual #3The facility shall keep a copy of the statement signed by the individual or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.Client Rights was reviewed with Individual #1, and Individual #2 by their Program Specialists. Individual #1 signed the Client Rights Statement on 1/22/2024. Individual #3 had a signed Client Rights statement dated 10/24/2023, however, it was accidently not filed in the chart when received. Statement was put in his chart on 1/18/2024. Individual #2 was missing 2 pages from the Client Rights Policy. All pages were emailed to the individual¿s mother who is his legal guardian on 1/18/2024 and returned signed by individual #2¿s guardian on 1/22/2024. 02/18/2024 Implemented
2380.39(b)(1)The CEO (Staff #1) has 9.5 hours of documented training for the 2023 training year.The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.Director of QA and Training reviewed the 2024 annual training profile for the CEO and confirmed that the correct amount of training hours (minimum of 12) have been assigned for CEO. 02/09/2024 Implemented
SIN-00218047 Renewal 01/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(a)Unused bathroom in kitchen area needs to be cleaned. The sink has rust and calcium deposits. The partition is also rusted. The toilet is dirty and has not been cleaned as reflected in the buildup in the bowl and surrounding areas of the toilet.Clean and sanitary conditions shall be maintained in the facility.A maintenance ticket was submitted by the Director of the Community Center on 2/1/2023 (attachment 7). The Director of Facilities looked at the bathroom on 2/1/2023 and confirmed that the toilet and surrounding area were cleaned by the Community Center's maintenance man. The toilet seat will be replaced, the rust and calcium deposits in the sink will be cleaned ) by 2/28/2023. The rusted partition will be removed ) by 2/28/2023. 02/28/2023 Implemented
2380.57Light to illuminate exit door from stage to multi-purpose room would not turn on.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.Bulbs were changed following inspection on 1/25/2023 by the Director of Facilities who was in the building following inspection on 1/25/2023. See attachment 3, 4, 5 and 6 for before and after pictures. 02/28/2023 Implemented
2380.89(b)The 1/7/22 fire drill was completed on a day when a majority of enrolled individuals were absent. There is not another documented drill from that month.Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average.On 1/31/2023, another fire drill was conducted when a majority of individuals were present. See attendance and fire drill log (attachment 8) 02/28/2023 Implemented
2380.111(a)Individual#1's record does not clearly document when their annual physical was completed. The provided document contained three different dates: 12/9/21, 12/23/21, which was crossed out, and 4/29/22, the date a TB test was read. Otherwise, the date information was added or reviewed is indeterminate, with no full physical clearly documented in 2022. This physical was also incomplete: it does not indicate if the individual's medical history was reviewed and does not capture immunization information. Individual#2's 9/8/22 physical is incomplete, missing the following information: documentation of yearly routine vaccines (such as a flu shot), vision and hearing screening information, an assessment of health maintenance needs, medical information pertinent to diagnosis in case of emergency, and an assessment of dietary needs. Individual#3's most recent physicals are dated greater than a year apart: 3/3/21 and 4/26/22. The 4/26/22 physical is incomplete, missing the following information: documentation of routine yearly vaccinations (such as a flu shot), vision and hearing screening information, a current TB test with results (an outdated TB test result from 9/16/20 is listed on the physical), and an assessment of the individual's dietary needs.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #1's mother was notified by the Program Specialist on 1/25/2023 of the issues with the previous physical. A physical exam is scheduled for 2/2/2023. The individual¿s mother stated she will return it on 2/6/2023. The Program Specialist will review the physical for completion and accuracy. The Program Specialist will contact the family if additional information is needed and document in Individual #1's file . Once completed, the Program Specialist will place the physical in the individuals chart. Individual #2's mother and guardian were notified by The Program Specialist on 1/31/2023 of the need to have the physical form completed. The individual's sister is taking the incomplete form to the doctor to have it completed accurately on Wednesday 2/1/2023. Asterisks were placed next to the sections that need further information by the Program Specialist. Physical will be returned to the Program Specialist who will review it for completion and accuracy. The Program Specialist will contact the family if additional information is needed and document in Individual #2's file. Once completed, the Program Specialist will place the physical in the individuals chart. Individual #3's Program Specialist notified the individuals mother on 1/23/2023 of the issues with the previous physical not being completed on time and missing documentation such as routine yearly vaccinations (such as a flu shot), vision and hearing screening information, a current TB test with results (an outdated TB test result from 9/16/20 is listed on the physical), and an assessment of the individual #3's dietary needs. A doctor¿s appointment is scheduled for 2/1/2023 at which time a TB test will be performed and all sections of the form will be completed. The Program Specialist will review the physical for completion and accuracy. The Program Specialist will contact the family if additional information is needed and document in Individual #3's file. Once completed the Program Specialist will place the physical in the individuals chart. 02/28/2023 Implemented
SIN-00144262 Renewal 10/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)In the Senior room, room #7, the outside corner of the room has missing plaster which exposes metal corners. The large table in this room has loose formica on its top and side.Floors, walls, ceilings and other surfaces shall be in good repair.Work order request form was submitted on 10/30/2018. Verbal request made to facilities on 10/29/2018. Repair started on 10/29 and completed on 11/5/2018. Ticket detail report attached with photo's of completed work as well as initial Work Order Request Form. See attachments #2,3,4. A ticket was submitted on 12/3/2018 to repair the loose formica on the table. See attachment #6. Table has been repaired. See attachment #7 and attachment #8, & #9. A Room Check form has been developed for staff to complete weekly or as needed requesting repairs in their program areas. See attachment #1 12/06/2018 Implemented
2380.58(b)The exposed metal corners in room 7 has the potential to cut fingers.Floors, walls, ceilings and other surfaces shall be free of hazards.Verbal request made to facilities on site on 10/29/2018. Work order request form was submitted on 10/30/2018. Repair started on 10/29 and completed on 11/5/2018. Ticket detail report attached with photo's of completed work as well as initial Work Order Request Form. See attachments 2, 3 & 4.A Room Check form has been developed for staff to complete weekly or as needed requesting repairs in their program areas. See attachment #1 11/05/2018 Implemented
2380.67(a)In room # 3 there is a highback black chair with a loose right armrest and staining in the seat.Furniture and equipment shall be nonhazardous, clean and sturdy.The highback black office chair was removed and disposed of from Room #3 and replaced with a burgundy office chair at the time of inspection. See attachment #5. A Room Check form has been developed for staff to complete weekly or as needed requesting repairs in their program areas. See attachment #1 10/26/2018 Implemented
2380.128(e)Staff person #1's training was not available for review upon request.Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.In May 2018, a Trainer specifically for the Community Center was hired. Original documentation will be kept on file at the Community Center. Copies will be kept in staff person #1's personnel file in Human Resources as well as all documentation of Community Center staff training . The Community Center trainer will file original in staff person #1's file on site. Original documentation of all trainings of all staff, will be kept in each staffperson's file on site at the Community Center. All original medication admin records and other training records were brought to the Community Center and corrected at time of inspection. All 10/26/2018 Implemented
SIN-00111441 Renewal 03/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Staff #1 had 23.25 hours of training during the current complete training year.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.A staff training report will be automatically generated with our Human Resources Information System (HRIS) on a monthly basis and sent to the supervisors. They will monitor to insure that staff, on average, complete 2 hours of training a month; and that certainly 24 hours of training is completed before the end of the year. [Program Designee will conduct routine monitorings to ensure continued compliance. JG] 05/02/2017 Implemented
2380.55(a)The sink and counter area located in Classroom #5, Wing B, was coated with soap scum.Clean and sanitary conditions shall be maintained in the facility.The janitor cleaned the sink and counter area in room 5, wing B of soap scum upon her arrival on the day of licensing. The janitor will clean and rinse sinks and counters, daily, after consumers have left for the day. Staff will check sinks and counters for cleanliness in their room/bathroom each morning, upon arrival. If needed, staff will clean and rinse sinks and counters, and report this to their Program Specialist. 05/12/2017 Implemented
2380.58(a)The recliner located in Classroom 6, Wing A, was torn on the lower right side, exposing the padding. The couch located in Classroom 3, Wing A, had fabric peeling off the backrest. A chair with a black wooden frame, located in Classroom 3, Wing B, had a broken arm rest which was detached from the frame, causing the chair to be unstable. A wooden dresser located in Classroom 4, Wing B, was missing a knob, a black bean bag chair in the room was tearing at the seams, and the vinyl recliner in the room had a torn left arm rest which exposed the padding and polyester filling. Floors, walls, ceilings and other surfaces shall be in good repair.The torn recliner in room 6, wing A was discarded. The couch in room 3, wing A, with fabric peeling off the backrest, was discarded. A new couch was purchased. The armrest of the black chair in room 3, wing B, was repaired. The missing knob was replaced on the wooden dresser located in room 4, wing B. The torn bean bag chair was discarded in room 4, wing B. The recliner in room 4, wing B with the torn armrest was discarded. Staff will check furniture weekly. Work orders will be completed by Program Specialist and forwarded to the maintenance department for repair or disposal of furniture. Photo's and copies of the receipts were forwarded by email to correlate with these citations. 05/09/2017 Implemented
2380.173(1)(ii)Individual #1's record did not contain information pertaining to 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.Individual #1's Client Information Sheet was updated to include identifying marks. Program Specialist will review Client Information Sheet upon admission to ensure that all personal information is completed. Information will be reviewed and updated at annual ISP meeting and upon receipt of physical examination form. Corrected Information Sheet was submitted via email. 05/05/2017 Implemented
SIN-00084469 Renewal 10/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Neutrogena sunscreen, which indicated to contact poison control if ingested, was unlocked in a cabinet in Room 6. Clorox wipes, Glade spray and Lysol disinfecting spray, which indicated to contact poison control if ingested, was unlocked in a cabinet in Room 5. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Sunscreen was removed from the cabinet in room 6 by the Associate Director at the time of inspection and placed in an area in the program specialist's office which is not accessible to individuals. The program specialists walk through each room on a daily basis. Checking for poisonous materials will now occur during their walk-thru. Program Specialists were trained on completion of walk-thru on 10/21/2015 Attachment #13 Clorox wipes, Glade Spray and Lysol disinfecting spray have been removed from Room 5 and placed in the janitors locked closet. Cleaning supplies used during the day are locked in an office not accessible to the individuals. Staff training on poisonous materials was completed on 10/21/2015. Attachment #14 10/21/2015 Implemented
2380.53(c)Clorox wipes, Glade spray and Lysol disinfecting spray, which indicated to contact poison control if ingested, were stored with diet soda in a cabinet in Room 5. Not all of the participants of the program can safely handle poisonous materials.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Poisonous materials have been removed from the cabinet in room 5. They were placed in the janitor's locked closet which is only used on her 3-11 pm shift. Any cleaning supplies used during the day are kept locked in an office not accessible to the individuals. The program specialists walk through each room on a daily basis. Checking for poisonous materials will now occur during their walk-thru. Program Specialists were trained on completion of walk-thru on 10/21/2015 Attachment #13 Staff training on poisonous materials was completed on 10/21/2015. Attachment #14 10/21/2015 Implemented
2380.58(a)There was a hole, approximately the size of a fist, located in the wall behind the bathroom door in Room 6.Floors, walls, ceilings and other surfaces shall be in good repair.The hole located in the wall behind the bathroom door in Room 6 was corrected during inspection. All repairs are the responsibility of the facilities department. Requests for maintenance are done through a work order and faxed to the appropriate department. On 10/12/2015, a door stop was placed at the bottom of the wall and on the floor in Room 6, in addition to all bathrooms, to prevent this from occurring again. Attachment #12 10/12/2015 Implemented
2380.111(c)(4)Individual #1's physical examination, dated 07/27/2015, did not include a vison or hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.On individual #1's physical examination dated 07/27/2015, the primary physician recommended a vision and hearing screening. A vision screening was completed 04/24/2015 by the individual's ophthalmologist. Her report was not forwarded to her primary physician. A copy of the vision exam has been placed in individual #1's file and attached to her physical examination. Attachment #9. Individual #1's mother has refused to take her to an ENT for a hearing screening. Individual #1's mother has written a letter and the letter has been placed in her file. Attachment #10. The nurse will be responsible for reviewing all physicals for completion and accuracy. The nurse will contact family members or medical providers for additional reports needed and document in the individuals files. A check off list will be completed by the nurse when physicals are received and placed in the nurse's file that contains all up to date physicals. Attachment #11 11/10/2015 Implemented
2380.113(c)(3)Staff #3's physical examination, dated 12/10/2013, and Staff #4's physical examination, dated 01/30/2015, did not include if the person was free of communicable disease.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.All staff physical exams will included a signed statement that the person is free of serious communicable diseases to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease to the extent that confidentiality laws permit, but is able to work in the facility if specific precautions are taken that will prevent spread of the disease to individuals. Employee #3's physical has been amended by the medical provider to indicate that she is free of communicable diseases. Attachment #5 The staff physical exam form has been amended to include instructions for medical providers on completing the form in it's entirety. Attachment #6 A letter has also been emailed to our primary medical provider for new employee physicals with these instructions. Attachment #7. The Human Resources Assistant will be responsible for monitoring completion of all employee physical forms and will initial the form to document that it has been reviewed. 11/13/2015 Implemented
2380.113(c)(4)Staff #4's physical examination, dated 01/30/2015, did not include information regarding any medical problems.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.All staff physical exams will included information of medical problems which might interfere with the safety or health of the individuals. Employee #4's physical has been amended by the medical provider to indicate that she is free of any physical conditions that would endanger the health of the consumers. Attachment #8 on 10/14/2015. The staff physical exam form has been amended to include instructions for medical providers on completing the form in it's entirety. Attachment #6 A letter has also been emailed to our primary medical provider for new employee physicals with these instructions. Attachment #7. The Human Resources Assistant will be responsible for monitoring completion of all employee physical forms and will initial the form to document that it has been reviewed. 11/13/2015 Implemented
2380.181(c)Individual #1's assessment, dated 07/24/2015, did not indicate the basis of the assessment. Individual #3's assessment, dated 10/05/2015, did not indicate the basis of the assessment. Individual #4's assessment, dated 09/01/2015, did not indicate the basis of the assessment.The assessment shall be based on assessment instruments, interviews, progress notes and observations.The statement, "This assessment was written with information gathered by observation, progress notes, interviews and/or assessment instruments", was added to the cover sheet on the assessment template as well as to the current assessments for individual #1, individual #3 and individual #4. The Associate Director will be responsible for reviewing assessments completed on a monthly basis for proper content. Staff training was completed on 10/12/2015. Attachment #2 and Attachment #3 10/12/2015 Implemented
2380.181(e)(5)Individual #1's assessment, dated 07/24/2015, did not include the ability to self-administer medication.The assessment must include the following information: The individual's ability to self-administer medications.Individual #1 is unable to self-administer medications. Assessment dated 7/24/2015 has been updated to reflect this by adding the statement, "unable to self-administer medications". Associate Director will be responsible for reviewing all assessments completed on a monthly basis for proper content. Information needed for each section of the assessment is in parenthesis under each heading. Staff training completed on 10/12/2015. Attachment #3 10/12/2015 Implemented
2380.181(e)(13)(iv)Individual #2's assessment, dated 07/02/2015, did not include progress and growth in the area of 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.Individual #2's assessment has been updated to explain her progress and growth in the area of socialization. The updated assessment was added to her file and sent to the team. The Associate Director will be responsible for reviewing all assessments completed on a monthly basis for proper content. Information needed in each section of the assessment is in parenthesis under each heading. Staff training completed on 10/12/2015. Attachment #4 11/05/2015 Implemented
2380.186(d)Individual #2's Individual Support Plan (ISP) reviews were not sent to the Supports Coordinator. 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.ISP reviews will be emailed to the Supports Coordinator upon completion, within 30 days of the ISP review. Proof of email to the SC will be printed and placed in the individual's file under correspondence. Program Specialist will add a reminder to send ISP reviews to supports coordinators to their schedule of each individual's ISP review. Individual #2's file was updated to include the email for October's ISP review. Staff training was completed on 10/12/2015 Attachment #1 10/23/2015 Implemented
Article X.1007Staff #1's was hired on 10/06/2014. The criminal background check was requested on 01/21/2015. Staff #2's was hired on 4/20/2015. The criminal background check was requested on 05/06/2015. When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Going forward, all clearances will be completed at the time a job offer is made to an applicant. The Human Resources recruiter is responsible for completing all clearances. A form has been created to ensure the clearances are completed before a new employee starts and is added to the data base. The form will be initialed and given to the Human Resources Assistant to verify compliance to ensure all clearances are completed prior to staring. Attachment #15 11/12/2015 Implemented
SIN-00068510 Renewal 10/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical dated 3/19/14 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.Individual #1 has a shunt. His most recent physical did not list this information. He lives with his family. The LPN will review all physicals and ensure compliance. Staff training was completed on 10/16/2014. [Individual #1's physical examination will be updated by the physician to include the above information. LAC 12-17-14] 11/07/2014 Implemented
2380.111(c)(11)Individual #2's physical dated 8/13/14 did not indicate the special instructions for the individual's diet.The physical examination shall include: Special instructions for an individual's diet.Individual #2 is on a pureed diet. Her most recent physical did not state this information. Individual #2 lives with her family. The LPN will review all physicals and ensure compliance. Staff training completed on 10/16/2014. Individual #2's physical was updated to include the pureed diet by the physician. 11/07/2014 Implemented
2380.173(1)(iv)Individual #3's record did not document their religious affiliation. Each individual's record must include the following information: Personal information including: Religious affiliation.Individual #3 was a recent new admission. The consumer admission paperwork is completed by the SC and family the PS reviews the paperwork at the intake meeting. The PS will ensure compliance. Staff training completed on 10/17/14. Individual #1's record was updated to include regligious affiliation. 11/07/2014 Implemented
SIN-00053176 Renewal 09/30/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual # 1's most recent physical examination was conducted 1/21/13 and the previous examination was completed 11/29/11.(a)  Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual was due for her annual physical on 11-29-12. Letter was sent 10-11-12 to inform her mother. On 11-2-12 second notice was sent to her mother. On 11-19-12 program specialist called mom about the physical. On 11-21-12 program specialist called the Supports coordinator. On 11-28-12 the program specialist spoke to Access staff in home supports provider about the physical. Mother does not drive. Mother was caring for grandson and unable to get physical completed until 1-21-13. (Copies of letters and documentations of contact will be sent to Walter) The nurse sends notices regarding upcoming physicals. The nurse and program specialist contact families via mail and phone to get the physical completed on time. The nurse will audit all individuals physical examinations to ensure that they are all conducted on an annual basis by 1/30/14. 11/15/2013 Implemented
2380.181(e)(4)Individual #2's assessment dated 8/13/13, did not include water safety.(e)  The assessment must include the following information: (4)  The individual's need for supervision.Water safety was added to the assessment. A copy will be sent to Walter for review. Program Specialist will ensure assessment contains all required information. Director will review/monitor for accuracy and compliance. 09/30/2013 Implemented
2380.185(b)Individual # 1, 2, 3, and 4 did not have outcome plans.(b)  The ISP shall be implemented as written.Individual outcomes were developed for individuals 1,2,3 and 4. Copies will be sent to Walter for review. Each program specialist will ensure each individual has an outcome and data collection sheets. Outcomes will be implement as written in the ISP. Director will review/monitor for accuracy and compliance. 11/18/2013 Implemented
2380.186(b)Individual # 2's 3 month review dated 9/26/13 did not include a signature of the individual. (b)  The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The individual is unable to sign her name. Contents was explained to individual and staff noted that the individual is unable to sign. Completed on 9/30/13 during inspection. Copy will be sent to Walter for review. Program specialist will ensure signature or notation of inability to sign. Director will review/monitor for compliance. 09/30/2013 Implemented