Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00187587 Renewal 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.182(c)The individual plan last updated 4/27/2021 for Individual #1, date of admission 7/6/2020, did not address the supervision needs while at the adult training facility.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Program Specialist requested needs be put into the ISP immediately after inspection 5/12/2021 05/12/2021 Implemented
SIN-00145696 Renewal 11/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(c)(3)Direct Service Worker #1, date of hire 12/11/17, had a physical examination, dated 11/29/17; however, the physical examination did not include a statement that the employee is free from a 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.55 PA Code Chapter 2380.113(c)(3)- 27.2 Upon recognition, Human Resources were immediately notified that DSP physical did not include the statement ¿free from communicable disease¿. Human Resource professionals have been trained to insure all physicals are complete in all areas. Donnie Black¿s physician was notified and corrected the error by documenting that she was free from communicable diseases. Human Resource professionals will ensure completion of all staff physicals in accordance with the above regulation upon arrival. In addition, the Director and/or Assistant Director shall review all DSP personnel records that are pertinent to the program prior to licensing each year as a second tier of review. The following documents were submitted to the licensing Inspector: Signed in-service training for Human Resource Professionals and a corrected DSP physical for Donnie Black. [Immediately, and upon completion, the Human Resource professionals shall review all staff persons physical examination to ensure all required information is included. (DPOC by AES, HSLS on 12/14/18)] 12/13/2018 Implemented
SIN-00106107 Renewal 01/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)The program specialist did not provide Individual #1's assessment completed 8/26/16 to the entire plan team members including the vocational program and the behavioral support provider.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).The assessment for individual #1 has been sent to the excluded team members (vocational program provider and behavioral support provider) on 1/9/2017. Program director has written and implemented a new policy which states that all members of the ISP team shall receive assessment documents at least 30 calendar days prior to the ISP meeting. All members who are listed in the current approved ISP shall be included as well as any new members who were present for the meeting but have not been added as a team member in the ISP. When members are added or no longer part of the team a request shall be made to the supports coordinator to update the ISP. To ensure ongoing monitoring of the correction, the chart review form that is used to ensure compliance in our records has been updated to reflect this regulation.[At least quarterly for at least 1 year, the program director shall review a 25% sample of aforementioned chart review forms and correspondence documentation showing the program specialist provided the individuals' assessment to all plan team members. (AS 1/18/17)] 01/19/2017 Implemented
2380.186(d)The program specialist did not provide Individual #1's ISP review documentation completed 3/29/16, 6/29/16, 9/29/16 and 12/29/16 to the entire plan team members including the vocational program and the behavioral support provider. 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 review documents were sent to the vocational program and the behavior support provider on 1/9/2017. Program director has written and implemented a new policy which states that all program specialists shall send the documents in 2380.186(d) to all members of the ISP team. All members who are listed in the current approved ISP shall be included as well as any new members who were present for the meeting but have not been added as a team member in the ISP. Whne members are added or no longer part of the team a request shall be made to the supports coordinator to update the ISP. To ensure ongoing monitoring of the correction, the chart review form that is used to ensure compliance in our records has been updated to reflect this regulation. [At least quarterly for at least 1 year, the program director shall review a 25% sample of aforementioned chart review forms and correspondence documentation showing the program specialist provided the individuals' ISP review documentation to all plan team members as required. (AS 1/18/17)] 01/19/2017 Implemented
2380.186(e)The program specialist did not notify the entire plan team members of the option to decline the ISP review documentation including the vocational program and behavioral support provider. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Right to decline notices have been sent to the remainder of the team members (vocational program provider and behavioral support provider) on 1/9/2017. Program director has written and implemented a new policy which states that all members of the ISP team shall receive letters giving them he right to decline ISP review documents. All members who are listed in the current approved ISP shall be included as well as any new members who were present for the meeting but have not been added as a team member in the ISP. When members are added or no longer part of the team a request shall be made to the supports coordinator to update the ISP. To ensure ongoing monitoring of the correction, the chart review form that is used to ensure compliance in our records has been updated to reflect this regulation.[Immediately, the program specialist(s) shall review all individuals' records to ensure all plan team members for all individuals have been notified of the option to decline the ISP review documentation. At least quarterly for at least 1 year, the program director shall review a 25% sample of aforementioned chart review forms and correspondence documentation showing the program specialist notified all plan team members as required of the option to decline the ISP review documentation. (AS 1/18/17)] 01/19/2017 Implemented
SIN-00087964 Renewal 01/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)The physical examination for Individual #1, completed on 12/9/15, did not include a review of previous medical history.The physical examination shall include: A review of previous medical history.The Program Specialist for individual #1 is currently attempting to acquire "the previous medical history" information that was missing from the physical form. All Program Specialists will review all physical assessment forms for individuals on their caseloads and attempt to acquire any information that was found to be left blank on the form. Program Specialists will document any attempts that have not yielded the information. The Program Director has written a new policy regarding the proper completion of physical assessment forms. All Program Specialists and the Assistant Director have been trained on the new policy and the expectations for proper completion of the physical form in compliance with the regulations. Agency physical form has also been revised to clearly note that all sections must be completed.[For 1 year after the receipt of the plan of correction the CEO or program director will review a 25% sample of completed physical examinations at least quarterly to ensure timely completion and all required elements are addressed. Missing information will be obtained by the Individuals physicians. Documentation of reviews shall be kept.(AS 2/25/16)] 01/31/2016 Implemented
2380.111(c)(5)The tuberculin skin tests for Individual #3 were completed on 8/14/13 and 9/17/15.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 Director has written a new policy regarding important dates and tracking them for compliance, including TB testing dates for all individuals enrolled at the progam. All Program Specialists and the Assistant Director have been trained on the policy including the expectations for tracking and maintaining compliance dates in relation to the regulations. A tracking system for important dates has been created and will be used by Program Specialists, Director, and Assistant Director to track dates and ensure compliance. The master spreadsheet will be placed on the shared network drive so that it can be accessed and updated by all parties. Upcoming due dates will be highlighted for easy recognition and notification that updates are necessary. All above mentioned professional staff have been trained on the method we will use for tracking dates.[For 1 year after the receipt of the plan of correction the CEO or program director will review a 25% sample of completed physical examinations at least quarterly to ensure timely completion and all required elements are addressed. Missing information will be obtained by the Individuals physicians. Documentation of reviews shall be kept.(AS 2/25/16)] 01/31/2016 Implemented
2380.111(c)(7)The physical examination for Individual #1, completed on 12/9/15, did not include an assessment of the Individual #1's health maintenance needs.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.The Program Specialist for individual #1 is currently attempting to acquire an "assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals" that was missing from the physical form. All Program Specialists will review all physical assessment forms for individuals on their caseloads and attempt to acquire any information found to be left blank on the form. Program Specialists will document any attempts that have not yielded the information. Program Director has written a new policy regarding the proper completion of physical assessment forms. All Program Specialists and the Assistant Director have been trained on the new policy and the expectations for proper completion of physical forms in compliance with the regulations. Agency physical form has also been revised to clearly note that all sections must be completed..[For 1 year after the receipt of the plan of correction the CEO or program director will review a 25% sample of completed physical examinations at least quarterly to ensure timely completion and all required elements are addressed. Missing information will be obtained by the Individuals physicians. Documentation of reviews shall be kept.(AS 2/25/16)] 01/31/2016 Implemented
2380.111(c)(10)The physical examination for Individual #1, completed on 12/9/15, 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.The Program Specialist for individual #1 is currently attempting to acquire the "medical information pertinent to diagnosis and treatment in case of an emergency" that was missing from the physical form. All Program Specialists will review all physical assessment forms for individuals on their caseloads and attempt to acquire any information that was found to be left blank on the form. Program Specialists will document any attempts that have not yielded the information. The Program Director has written a new policy regarding the proper completion of physical assessment forms. All Program Specialists and Assistant Director have been trained on the new policy and the expectations for proper completion of forms in compliance with the regulations. Agency physical form has also been revised to clearly note that all sections must be completed..[For 1 year after the receipt of the plan of correction the CEO or program director will review a 25% sample of completed physical examinations at least quarterly to ensure timely completion and all required elements are addressed. Missing information will be obtained by the Individuals physicians. Documentation of reviews shall be kept.(AS 2/25/16)] 01/31/2016 Implemented
2380.181(a)The initial assessment for Individual #2, admitted 8/28/15, was completed on 11/11/15.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.Program Director has written a new policy regarding important dates and tracking them for compliance, including the functional assessments for all individuals. All Program Specialists and the Assistant Director have been trained on the policy including the expectations for tracking and maintaining compliance dates in relation to the regulations. A tracking system for important dates has been created and will be used by Program Specialists, Director, and Assistant Director to track dates and ensure compliance. The master spreadsheet will be placed on the shared network drive so that it can be accessed and updated by all parties. The spreadsheet will highlight due dates to assist with ensuring updates are made for compliance. All above mentioned professional staff have been trained on the method we will use for tracking dates/compliance.[For 1 year after the receipt of the plan of correction the CEO or program director will review a 25% sample of completed assessments at least quarterly to ensure timely completion by the program specialist. Documentation of reviews shall be kept.(AS 2/25/16)] 01/31/2016 Implemented
SIN-00071115 Renewal 01/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(5)The assessments completed for the following individuals did not indicate the individual's ability to self-administer medication: #1, #2, #3, #4, #5 and #6. The assessment must include the following information: The individual¿s ability to self-administer medications.In response to the licensing inspection for certificate #426250 held on 1/9/2015 the plan of correction is as follows: In order to comply with regulation PA 2380.181(e) (5) in regards to assessment for the progress towards self administration of medication, all individuals sampled have had their assessments updated to reflect their progress, if any, regardless of their medication status. The program director has written a policy outlining the requirement to fully complete the self-administration of medication portion of the functional assessment and to update annually thereafter. All individual records will be reviewed to make sure that necessary updates have or will be made in accordance with the regulation. Documents sent to the licensing administrator include updated assessment pages for clients sampled (9), policy document, and in-service sign in sheet for Employment Option Center Program Specialists. Plan of correction implemented by Damon A. Krynicki, EOC Director on 2/3/2015. 02/03/2015 Implemented
SIN-00056568 Renewal 01/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)The facility did not alternate exit routes for the monthly fire drills conducted from 9/17/2012 to 12/19/2013. The Main/Front Exit, the Lunch Room Exit and the Back Room Exit were used in every monthly fire drill. (e)  Alternate exit routes shall be used during fire drills.Effective immediately, in order to ensure compliance with the above regulation the Employment Option Center supervisor(s) (Director and/or Assistant Director) conducting the fire drill will block one of the three exits one time per quarter, randomly, so that individuals and staff will be required to use alternate exit routes when evacuating the building. This will ensure that alternate routes are being used a minimum of 4 times per year. The Moon Twp. Fire Chief conducted the annual fire inspection and evacuation on 1/10/2014 at the Employment Option Center. At this time he determined that the maximum reasonable time for the building to be evacuated is 4 minutes 0 seconds. This time includes the use of alternate exit routes and the possible blockage of an exit during a fire. The documentation of the use of alternate routes will be on the monthly fire drill record. The fire drill supervisor completing the form will mark only the routes used while omitting any route not used in the event of a blocked exit. Exits not used during the drill will not be marked on the fire drill record and the fire drill supervisor will detail any blocked exit routes in the comments section of the form. During fire drills, the supervisor will stand at the point of the fire with a large flashlight to indicate the location of the fire and the blockage, if any, of an exit. The director has also written an updated policy regarding the protocol for conducting fire drills at the EOC which also goes into effect immediately and will remain so going forward. The following attachments have been sent to the licensing inspector: ¿Annual fire drill/inspection conducted by Moon Twp. Fire Chief Charles Belgie, Jr. ¿Fire Drill Policy ¿In-service sign in sheet for Director, Assistant Director, and Program Specialists (4) ¿Sample fire drill record documenting a blocked exit ¿2014 Fire Drill Schedule 01/19/2014 Implemented
SIN-00241812 Renewal 03/28/2024 Compliant - Finalized
SIN-00223076 Renewal 04/19/2023 Compliant - Finalized
SIN-00204480 Renewal 05/04/2022 Compliant - Finalized
SIN-00165529 Renewal 11/07/2019 Compliant - Finalized
SIN-00125877 Renewal 12/12/2017 Compliant - Finalized
SIN-00041091 Renewal 09/24/2012 Compliant - Finalized