Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227307 Renewal 07/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1's physical examination completed 1/07/2022 did not include a hearing screening, It states not applicable.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual is scheduled for his annual hearing screening on July 27, 2023. He will receive these annually unless otherwise specified by his PCP. 07/13/2023 Implemented
6400.141(c)(6)Individual #1 had a Tuberculin skin test completed 12/06/2019 and then again 1/07/2022.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual is currently within compliance for TB testing and will receive his next test in January 2024 07/13/2023 Implemented
6400.46(c)Direct Service Worker #1, date of hire 10/26/2022, was trained in first aid techniques 12/15/2022.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.Per the discussion under 6400.46 (c) - "this regulation is specific to times when the provider is transporting the individual." As this director care worker is a night shift staff person who is at work when they are asleep, she has - to this date - never transported the individuals. Therefore, her 12/15/2022 certification date should be sufficient. 07/13/2023 Implemented
6400.46(d)Direct Service Worker #2, date of hire 7/02/2010, had training in First aid Heimlich techniques and cardio-pulmonary resuscitation on 1/28/2022. There is no record of any other trainings in first aid, Heimlich techniques and cardio-pulmonary resuscitation for Direct Services Worker #2.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Direct care service worker is currently certified in CPR, heimlich techniques, and first aid. He is not due for recertification until 2024. 07/13/2023 Implemented
SIN-00209143 Renewal 08/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)Individual #1's physical examination, completed 7/21/22, did not include medical history. This section was left blank.The physical examination shall include: A review of previous medical history. Individual#1's physical form was returned to the physician and filled out in its entirety. 09/10/2022 Implemented
6400.141(c)(9)Individual #1 had a prostate examination on 5/10/21, and then again on 7/26/22.The physical examination shall include: A prostate examination for men 40 years of age or older. A spreadsheet of all annual appointments will be created and checked weekly to ensure all appointments are scheduled and attended within the required timeframe. 09/10/2022 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 7/21/22, did 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. Individual #1's physical form was returned to the physician to fill out in its entirety. 09/10/2022 Implemented
SIN-00192045 Renewal 08/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The home conducted monthly fire drills from 11/30/20 through 8/22/21. The only drill held during sleeping hours was 8/22/21.A fire drill shall be held during sleeping hours at least every 6 months. Residential Program Manager will update the fire drill forms, retrain staff on the regulations on fire drills, and schedule at least two overnight fire drills a year between the hours of 2am and 4am. 10/01/2021 Implemented
6400.141(c)(3)Individual #1's 7/28/21 tetanus, diphtheria and pertussis immunization was administered by a certified medical assistant.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. 6400.141d Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant.Clinical Coordinator will create and attach a bright pink form to all immunization orders, explaining regulations and the approved medical professionals we require to administer and read immunization results and TB tests. 10/01/2021 Implemented
6400.141(c)(4)Individual #1's 7/21/21 physical examination did not include a vision screening. The area was left blank.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Clinical Coordinator will update all medical forms to include required information. Clinical Coordinator will also highlight all areas needing to be completed by a physician, and be the designated staff to accompany the individuals to their annual exams, including the annual physical exam. 10/01/2021 Implemented
6400.141(c)(11)Individual #1's 7/21/21 physical examination did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.. The area was left blank.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. Clinical Coordinator will update all medical forms to include required information. Clinical Coordinator will also highlight all areas needing to be completed by a physician, and be the designated staff to accompany the individuals to their annual exams, including the annual physical exam. 10/01/2021 Implemented
6400.141(c)(12)Individual #1's 7/21/21 physical examination did not include physical limitations of the individual. This area was left blank.The physical examination shall include: Physical limitations of the individual. Clinical Coordinator will update all medical forms to include required information. Clinical Coordinator will also highlight all areas needing to be completed by a physician, and be the designated staff to accompany the individuals to their annual exams, including the annual physical exam. 10/01/2021 Implemented
SIN-00177362 Renewal 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Unannounced fire drills were not held in October 2019 and November 2019. An unannounced fire drill shall be held at least once a month. The Program Specialist will review this regulation with Direct Care staff to ensure compliance and understanding. This item will also be added to the Residential Program Calendar to remind the Director and Program Specialist of the approaching due date at the end of each month. [Immediately, the CEO or designee shall educate all staff persons responsible for conducting fire drills of the requirements of fire drills as per 6400,112a-112i. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. (DPOC by AES,HSLS on 11/30/20)] 10/30/2020 Implemented
6400.113(c)There was not a written record of fire safety training for Individual #1. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.This documentation was unable to be located. 2020 Individual Fire Safety Training will be scheduled as soon as possible due to limited availability of the Fire Dept due to COVID-19. This item will be added to the Residential Program (shared) calendar to ensure that the Director and Program Specialist are aware of approaching the due date.[Immediately, Individual #1 shall be trained in fire safety. Immediately and at least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure fire safety training has been completed, timely, and retraining shall occur as needed. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are educated in fire safety, timely, and documentation is kept as required. (DPOC by AES,HSLS on 11/30/20)] 10/30/2020 Implemented
6400.181(a)Individual #1 had an assessment completed on 2-5-19 and then again on 3-11-20. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The Director will retrain the Residential Program Manager on regulations pertaining to Individual Assessments. The Director will conduct an inspection prior to the Individual Assessments being sent out to the ISP team to ensure compliance. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of all individuals' assessments and educate the program specialist on the system. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 11/20/20)] 10/16/2020 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 11-25-18 and then again on 2-25-20.The home 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 home and annually thereafter.All annual paperwork, including Individual Rights, will be sent out no later than December 31 annually. This paperwork will be due to be returned to the agency no later than January 15 annually. This item will be added to the Residential Program (shared) calendar to ensure that the Director and Program Specialist are reminded of approaching the due date. 12/31/2020 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 3-11-20 to plan team members on 3-11-20 for the the plan team meeting on 3-13-20.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The Director will retrain the Residential Program Manager on regulations pertaining to Individual Assessments. The Director will conduct an inspection prior to the Individual Assessments being sent out to the ISP team to ensure compliance. [Documentation of aforementioned training shall be kept. At least quarterly, for 1 year, the CEO or designee shall audit the correspondence documentation showing the program specialist provided all individuals' current assessments to the individual's plan team members, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 11/20/20)] 10/16/2020 Implemented
SIN-00137000 Renewal 06/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1 had a statement acknowledging receipt of the information on rights signed on 12/30/16 and then again 1/25/18.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Program Specialist will create and maintain an annual tracking spreadsheet with the dates listed from the previous year in order to maintain accuracy. [Immediately and continuing at least quarterly for 1 year, the CEO or designated management staff shall audit the aforementioned tracking system and a 25% sample of statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights to ensure timely completion. Documentation of audits shall be kept. (AS 7/12/18)] 06/28/2018 Implemented
6400.186(a)The program specialist completed ISP reviews for Individual #1 for the review period of 8/1/17 to 10/31/17 on 11/28/17, for the review period of 11/1/17 to 1/31/18 on 2/27/18, and for the review period of 2/1/18 to 4/30/18 on 5/22/18. The program specialist completed ISP reviews for Individual #2 for the review period of 7/1/17 to 9/30/17 on 10/24/17 and for the review period of 10/1/17 to 12/31/17 on 1/17/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program Specialist will schedule and hold meetings with the individual within the first week after the review period has ended. Program Specialist is aware that in order to complete the quarterly review, it must be reviewed with the individual within fifteen days after the review period has ended. Program Specialist will create and maintain an annual tracking spreadsheet in order to maintain accuracy. [Immediately and continuing at least quarterly for 1 year, the CEO or designated management staff shall audit the aforementioned tracking system and a 25% sample of ISP review to ensure timely completion. Documentation of audits shall be kept. (AS 7/12/18)] 07/09/2018 Implemented
SIN-00117871 Renewal 07/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)The program specialist did not provide Individual #1's assessment, dated 1-9-17, to the plan team members for an ISP meeting on 2/10/17. (f) The program specialist shall provide the assessment to the SC, 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). Program Specialist has created an up to date spreadsheet with all current consumer annual assessment due dates. Program Specialist will utilize this spreadsheet in order to maintain accuracy with due dates in order to ensure that the annual information is provided to the plan team members thirty days prior to the annual meeting. [At least quarterly for 1 year, the CEO or designee shall review the aforementioned tracking system to ensure the program specialist(s) is providing all individuals' assessments to the plan team members, timely. Documentation of the reviews shall be kept. (AS 8/11/17)] 07/30/2017 Implemented
Article X.1007Easter Seals is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Direct Service Worker #1, date of hire 8-24-16, resided in Maryland until 3/2/16, did not have a criminal history check submitted in accordance with the Older Adult Protective Services Act (OAPSA) through the Pennsylvania Department of Aging. 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.Incorrect program office was selected during the initial steps of completing the criminal history check. The appropriate staff have been notified of what program office to request this check from, Department of Aging. [On 8/25/17, Direct Service Worker #1 was registered with Cogent for a criminal background check through the Department of Aging. Upon receipt the CEO or designated management staff persons shall review. Immediately and upon hire, the CEO or designee shall review all staff persons prior residence information and submit criminal history record check in accordance with OAPSA as required. Within 30 of receipt of the plan of correction, CEO or designee who is responsible for completing criminal history checks, shall review the OAPSA law information available on the Department's website (dhs.pa.gov) to ensure all staff persons have criminal history checks as required. (AS 9/22/17)] 07/30/2017 Implemented
SIN-00098385 Renewal 07/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(13)The physical examination, dated 7/6/16, for Individual #1 does not include allergies or contraindicated medications.The physical examination shall include: Allergies or contraindicated medications.The agency Annual Physical Form was not completed in its entirety by Easter Seals / Physician. The form will be updated for each individual enrolled in 6400 programming, to include "self populated" areas that are completed prior to the actual annual physical exam. The form will also include "highlighted" areas that the doctor must complete. Both changes will allow for assurance that the Annual Physical Form is completed in its entirety. [Individual #1's physical examination was updated on 9/7/16 to include allergies or contraindicated medications. Within 2 weeks of receipt of the plan of correction, the division director shall review the "Annual Residential Physical Form" and revise to include all required information areas as specified in 6400.141.(c)(1)-(15) where the licensed physician, certified nurse practitioner or licensed physician's assistant are able to complete, sign and date as required. Within 30 days of receipt of the plan of correction, the division director shall review with the program specialist(s) what individual physical examinations are required to include as per 6400.141.(c)(1)-(15) and sign and date upon review. Within 30 days of receipt of the plan of correction and upon receipt and prior to entering into the individuals' records, the program specialist(s) shall review all individuals' current physical examinations to ensure all required information is included and there are not required areas left blank and will obtain missing information from the completing licensed physician, certified nurse practitioner or licensed physician's assistant. At least quarterly, the division director shall review a 25% sample of individual physical examination to ensure all required information is included and completed by a licensed physician, certified nurse practitioner or licensed physician's assistant. Documentation of all reviews shall be kept. (AS 9/7/16)] 08/08/2016 Implemented
6400.141(c)(14)The physical examination, dated 7/6/16, for Individual #1 does 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 agency Annual Physical Form was not completed in its entirety by Easter Seals / Physician. The form will be updated for each individual enrolled in 6400 programming, to include "self populated" areas that are completed prior to the actual annual physical exam. The form will also include "highlighted" areas that the doctor must complete. Both changes will allow for assurance that the Annual Physical Form is completed in its entirety.[Individual #1's physical examination was updated on 9/7/16 to include "emergency medical information." Within 2 weeks of receipt of the plan of correction, the division director shall review the "Annual Residential Physical Form" and revise to include all required information areas as specified in 6400.141.(c)(1)-(15) where the licensed physician, certified nurse practitioner or licensed physician's assistant are able to complete, sign and date as required. Within 30 days of receipt of the plan of correction, the division director shall review with the program specialist(s) what individual physical examinations are required to include as per 6400.141.(c)(1)-(15) and sign and date upon review. Within 30 days of receipt of the plan of correction and upon receipt and prior to entering into the individuals' records, the program specialist(s) shall review all individuals' current physical examinations to ensure all required information is included and there are not required areas left blank and will obtain missing information from the completing licensed physician, certified nurse practitioner or licensed physician's assistant. At least quarterly, the division director shall review a 25% sample of individual physical examination to ensure all required information is included and completed by a licensed physician, certified nurse practitioner or licensed physician's assistant. Documentation of all reviews shall be kept. (AS 9/7/16)] 08/08/2016 Implemented
SIN-00081767 Renewal 07/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-inspection for the home was completed on 3-6-2015. The agency license expired on 6-4-2015The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A chart has been established with self assessment due dates for each home.[As per conversation with PS on 9/16/15, PS established chart with the the 3-6 month prior to expiration of COC as required. PS and the Division Manager will be responsible to completing the SA in the required time frames as required. (AS 9/16/15)] 08/08/2015 Implemented
6400.186(d)The ISP review documentation for Individual #1 dated 5/15/15 was not sent to the entire team.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Documentation will be sent to Andrea Kurtz that verifies that the ISP review documentation was sent to entire team. [As per conversation with PS on 9/16/15, PS will be responsible for ensuring ISP reviews are sent to the entire team and supporting documentation is maintained in the Individuals' records. A review of all Individuals' records to ensure the entire teams received ISP reviews was completed by the PS and will continue at least every other month.(AS 9/16/15)] 08/08/2015 Implemented
SIN-00157283 Renewal 06/18/2019 Compliant - Finalized
SIN-00065680 Renewal 07/09/2014 Compliant - Finalized