Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00205055 Renewal 05/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.75(a)(1)During the inspection conducted 5/11/2022, at1:25PM the refrigerator in the "South Room" program area contained an uncovered Styrofoam bowl of celery and carrot sticks and a steel bowl of an unknown food with a wooden spoon, that is loosely covered by a storage bag sitting on top of the bowl.If the facility provides meals for clients or a food service training facility program in the facility, the following conditions shall be met: (1) Food while being stored, prepared, served and transported shall be protected from contamination. Food shall be stored in containers which prevent penetration of insects and rodents.Food that was not properly stored was removed from refrigerator immediately. In the future all food will be stored in storage baggies or containers to be protected from contamination. All staff will be trained that food needs to be stored in storage baggies or containers which prevent contamination. 06/15/2022 Implemented
2390.48(b)(1)Direct Service Worker #2, date of hire 10/25/2021, had orientation training from 10/25/2021 to 10/29/2021 which included training in the application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships, this was completed by self-reading the material.The orientation must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.Direct Service Worker #2, will complete training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. They will complete this required training by 6/30/22 via my ODP webcast and obtain their certification from ODP. 06/30/2022 Implemented
2390.48(b)(2)Direct Service Worker #2, date of hire 10/25/2021, had orientation training from 10/25/2021 to 10/29/2021 which included training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, this was completed by self-reading the material.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Direct Service Worker #2, completed training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. She completed this required training on 5/20/22 via my ODP webcast and obtain their certification from ODP. 05/20/2022 Implemented
2390.48(b)(4)Direct Service Worker #2, date of hire 10/25/2021, had orientation training from 10/25/2021 to 10/29/2021 which included training in recognizing and reporting incidents, this was completed by self-reading the material.The orientation must encompass the following areas: Recognizing and reporting incident.Direct Service Worker #2 ,will complete training recognizing and reporting incidents . They will complete this required training by 6/30/22 via my ODP webcast and obtain their certification from ODP. 06/30/2022 Implemented
2390.49(c)(1)Chief Executive Operator #3 and Direct Service Worker #4 had training in the application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships. during the annual training year of 5/01/2021 to 4/30/2022, this was completed by self-reading the material.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.CEO #3, completed training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. She completed this required training on 5/20/22 via my ODP webcast and obtained her certification from ODP. Direct service Work #4 had completed this training via my ODP and has the certification from when she completed it on February 9,2022. It was in her training file provided. 05/20/2022 Implemented
2390.49(c)(2)Program Specialist #1, Chief Executive Operator #3, Direct Service Worker #4, and Direct Service Worker #5 had training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the annual training year of 5/01/2021 to 4/30/2022, this was completed by self-reading the material.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Program Specialist #1, CEO #3, Direct Service Worker #4 and Direct Service Worker #5 will complete training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. They will complete this required training by 6/30/22 via my ODP webcast and obtain their certification from ODP. 06/30/2022 Implemented
2390.49(c)(5)Program Specialist #1, Direct Service Worker #4, and Direct Service Worker #5 had training in the safe and appropriate use of behavior supports during the annual training year of 5/01/2021 to 4/30/2022, this was completed by self-reading the material.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with a client.Program Specialist #1, Direct Service Worker #4 and Direct Service Worker #5 will complete training on the safe and appropriate use of behavior supports specific to those they work with. They will complete this required training by 6/30/22 via in person with the BSP who wrote the plans. 06/30/2022 Implemented
2390.152(c)Individual #1, date of admission 12/01/2021, individual service plan last updated 4/14/2022 has a previous provider listed under day supervision.The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment.Immediately correct Individual #1 individual service plan so all content was correct and previous provider listed under day supervision was removed and PWAC added 5/17/22. Train Program Specialist on 2390 ISP required paperwork and regulated documents on 5/17/22. Audit of all PWAC individuals binders to be completed by another Program Specialist/Supervisor to ensure all assessments, ISP required paperwork, and regulated documents are in compliance by 6/27/22. Audit reports to be given to VP of Programs and Compliance for review and to ensure any findings are corrected immediately. 06/27/2022 Implemented
SIN-00119764 Renewal 08/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(b)(10)Monthly documentation was not completed prior to January 2017 for Individual #1 date of admission 8/28/00, Individual #3 date of admission 12/4/89, and Individual #4 date of admission 8/15/16, and Individual #5 date of admission 6/28/10.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of a client's participation and progress toward outcomes.This was a correction implemented on January 2017. This was noted by agency last year and was self corrected. It could not be corrected for months previous. All program staff were trained on their responsibilities regarding completing monthly progress notes as required by the 2390 and 51 regulations on 8/18/17. Documentation will be on file at agency location of training material and signatures of all Program Specialist who were trained. Monthly staff meetings beginning September 2017 a peer review will be completed of 2 individuals binders per each Program Specialist caseload of the previous month's ISP documentation to ensure compliance. Documentation will be kept on file at agency location of each peer review. 08/31/2017 Implemented
2390.151(a)Individual #1 had an assessment completed 1/21/16 and then again 2/7/17. Each client 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.All program staff were trained on their responsibilities regarding completing assessments annually on 8/18/17. Documentation will be on file at agency location of training material and signatures of all Program Specialist who were trained. A ISP tracking tool has been developed for each Program Specialist to utilize to track when ISP assessments and other ISP related responsibilities are to occur. Review of this ISP tracking tool will be reviewed monthly at staff meetings. Documentation will be kept on file at agency location of each peer review. 08/31/2017 Implemented
2390.151(f)The program specialist did not provide the assessment dated 2/7/17 for Individual #1 to all plan team members including the residential provider and behavior supports. The program specialist provided Individual #1's assessment dated 2/7/17 to the supports coordinator on 2/8/17 for the ISP meeting on 3/2/17. The program specialist did not provide the assessment dated 3/31/17 for Individual #2 to all plan team members including the residential provider and behavior supports. The program specialist did not provide the assessment dated 12/12/16 for Individual #3 to all plan team members including the parents. The program specialist did not provide the assessment dated 2/7/17 for Individual #4 to all plan team members including the residential provider and behavior supports. The program specialist provided Individual #4's assessment to the supports coordinator on 2/9/17 for the ISP meeting on 3/16/17. 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).All program staff were trained on their responsibilities regarding sending out assessments to all plan team members on 8/18/17. Documentation will be on file at agency location of training material and signatures of all Program Specialist who were trained. Monthly staff meetings beginning September 2017 a peer review will be completed of 2 individuals binders per each Program Specialist caseload of the previous month's ISP documentation to ensure compliance. Documentation will be kept on file at agency location of each peer review. [Immediately, the program specialist shall provide the most recent assessments for Individuals' #1, #2, #3, #4 to the plan team members who were not provided the reviews. Immediately, the program specialist(s) shall review the correspondence documentation for all individuals' assessment and all individuals' records including ISPs and invitation letters to ensure all plan team members were provided the individual's assessment, as required. Prior to the program specialist providing the assessments to the plan team members, the program specialist shall review the individuals' records including ISPs, invitation letters and other documentation to ensure all plan team members are provided the individuals' assessments, timely. At least quarterly for 1 year, a designated management staff shall review the correspondence documentation and tracking system to ensure all plan team members are provided individuals' assessments, timely. Documentation of reviews shall be kept. (AS 9/1/17)] 08/31/2017 Implemented
2390.156(d)The program specialist did not provide the ISP reviews dated 8/1/16, 11/2/16, 2/21/17, and 5/18/17 for Individual #1 to all plan team members including the supports coordinator, the parent, the residential provider, and the behavior specialist. The program specialist did not provide the ISP reviews dated 4/13/17 and 7/12/17 for Individual #2 to all plan team members including the supports coordinator, the residential provider, and the behavior specialist. The program specialist did not provide the ISP reviews dated 9/29/16, 12/12/16, 3/15/17, and 6/19/17 for Individual #3 to all plan team members including the supports coordinator and the parents. The program specialist did not provide the ISP reviews dated 9/14/16, 12/12/16, 3/14/17, and 6/19/17 for Individual #4 to all plan team members including the supports coordinator, the parent, the residential provider, and the behavior specialist. 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.All program staff were trained on their responsibilities regarding providing ISP reviews to all team members as required 30 days after the ISP review with the individual on 8/18/17. Documentation will be on file at agency location of training material and signatures of all Program Specialist who were trained. Monthly staff meetings beginning September 2017 a peer review will be completed of 2 individuals binders per each Program Specialist caseload of the previous month's ISP documentation to ensure compliance. Documentation will be kept on file at agency location of each peer review.[Immediately, the program specialist shall provide at least the most recent ISP reviews for Individuals' #1, #2, #3, #4 to the plan team members who were not provided the reviews. Immediately, the program specialist(s) shall review the correspondence documentation for all individuals' most recent ISP review and all individuals' records including ISPs and invitation letters to ensure all plan team members were provided at least the most recent ISP review, as required. Prior to the program specialist providing the ISP reviews to the plan team members, the program specialist shall review the individuals' records including ISPs, invitation letters and other documentation to ensure all plan team members are provided the individuals' ISP reviews, timely, as required. At least quarterly for 1 year, a designated management staff shall review the correspondence documentation and tracking system to ensure all plan team members are provided individuals' ISP review, timely, as required. Documentation of reviews shall be kept. (AS 9/1/17)] 08/31/2017 Implemented
SIN-00077882 Renewal 09/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.33(b)(15)The program specialist did not inform the plan team members for Individual #1 of the option to decline the ISP review documentation.The program specialist shall be responsible for the following: Informing plan team members of the option to decline the ISP review documentation as required under §  2390.156(e).Sign in sheet has been revised to include acceptance of documentation or declination of ISP review information. VP of Rehabilitation will review quarterly information for required documentation. (Letters have been sent to ISP team mmbers and copies have been placed in files.) 11/23/2015 Implemented
2390.85(a)-1A fire drill was conducted on 2/27/15. The previous fire drill was conducted on 11/11/14.A fire drill shall be held at least every 90 calendar days. Fire drills are now expected to be held every 60 days. Information relating to drills and/or bell tests are reviewed by the safety committee at their monthly meeting. (first Monday of each month.) (NOTE: drill was knowingly past 90 days due to the extrem weather conditions and concern for participants' safety and health. 11/26/2015 Implemented
2390.85(a)-2The record of the fire drill conducted on 11/11/14 did not include the hypothetical location of the fire. The record of fire drills conducted on the following dates did not include the evacuation times: 11/11/14, 10/28/14, 9/16/14, and 7/21/14.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.Hypthtical location is required and will be reviewed by the safety committee at their monthly meetings including evacuation times. (first Monday of each month.)[A copy of a memo dated 10/2/15 issued to the safety committee members and available for all staff to read as per VP of administration was submitted to department on 10/6/15. In addition to the safety committee review, VP or administration will review fire drill documentation with in 24 hours of the drill being completed to ensure documentation is accurately recorded, documentation of the reviews shall be kept. (AS 11/23/15)] 11/23/2015 Implemented
2390.151(a)The most recent assessment for Individual #1 was completed on 11/14/15. The previous assessment was not dated. Compliance cannot be measured.Each client 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.Staff have been instructed to complelte documentation as required. This is being reviewed by the VP of Rehab during quarterly revie of records. [A copy of said memo detailing requirements was submitted and receieved by the department. Confirmation of said quarterly reviews by VP of Rehab shall be kept. (AS 11/23/15)] 11/23/2015 Implemented
2390.151(f)The program specialist provided Individual #2's assessment dated 7/21/15 to the SC and plan team members on 7/21/15 for an ISP meeting held on 8/4/15. 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).A calendar has been developed indicating ISP date an tme frame for advance notice. This will be reveiwed quarterly by the VP of Rehab to insure requirements are met. 11/23/2015 Implemented
2390.156(d)The following ISP review documentation for Individual #1 was not sent to the entire plan team: 2/20/15 to 5/21/15; 11/14/14 to 2/20/15; and 8/14/14 to 11/14/14. The following ISP review documentation for Individual #3 was not sent to the entire plan team: 3/19/15 to 6/18/15; 12/11/14 to 3/19/15; 9/15/14 to 12/11/14; and 6/19/14 to 9/15/14. 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.Sign in sheet has been revised to include acceptance of documentation or declination of ISP review information. VP of Rehabilitation will review quarterly information for required documentation. [VP of Rehabilitation will review ISPs, ISP meeting invitation letters and other documentation for all individuals' entire team members and send ISP review documentation to the entire who has not declined to receive, confirmation documentation will be kept in records. (AS 11/23/15)] 11/23/2015 Implemented
SIN-00061059 Renewal 09/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.112(a)-2Individual #2's orientation form is dated 4/7/14; however, the Program Specialist indicated orientation did not occur on that date.The date of the orientation shall be written in the client's record.At a meeting of all rehabilitation staff on 9/12/2014 program specialists were informed to be sure to double check dates so that orientation and intake dates are correct. 09/12/2014 Implemented
2390.151(e)(10)The Lifetime Medical History for Individual #3 did not address the Dilation and Curettage surgery that was performed on 11/2/12 due to Dysfunctional Uterine Bleeding. The assessment must include the following information: A lifetime medical history.At meeting of all rehabilitation staff on 9/12/2014 staff were informed to include the lifetime medical history from the ISP rather than the current brief history that was previously used.[All individual records will be reviewed to ensure records include a lifetime medical history. (AS 10/20/14)] 09/12/2014 Implemented
2390.151(f)The 2/26/14 assessment, for Individual #3, was not sent to the all team members within 30 days of the ISP meeting held on 2/26/14. 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).At meeting of all rehab staff on 9/12/2014, program specialists were informed to set email reminders for the 30 day limit to distribute assessments to team members within required time frames. Additional email alert to VP of Rehab as additional reminder backup. 09/12/2014 Implemented
2390.156(e)The Program Specialist did not notify the team of the option to decline Individual #1's ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Letter of declination was sent that day to team member and was received back on 9/12/2014. Notification given to all rehab team members thath declination letters will be3 offered at the first quarterly meeting of all new participants 09/12/2014 Implemented
SIN-00048834 Renewal 07/24/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.621. The kitchen floor under the sink was unsanitary. There was a buildup of grime, grease and food. 2. There was no soap or hand drying options next to hand washing sink in the kitchen. 3. The slow cooker was covered in old caked on food on the outside of the holder. 4. The bathroom located in the woodshop was unsanitary. There was grime buildup inside the and around the handles. Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.The floor under the kitchen sink has been cleaned. Soap and hand towel dispenser placed at hand-washing sink. Slow cooker cleaned. Woodshop bathroom cleaned. Memos to kitchen, janitorial and safety committee to make sure areas are kept clean. Pictures taken08/01/2013 for verification.[The cleanliness of these areas will be additionally noted in the monthly building inspection checklist by 8/15/13. Documentation shall be kept. The Director will audit the checklists and physical site every other month to ensure that no unsanitary conditions exist in the facility. (CHG 8/6/13)] 08/02/2013 Implemented
2390.84(a)The fire extinguisher in the basement cutting room was undercharged. (a) There shall be at least one fire extinguisher with a minimum 10ABC rating for each floor including the basement. If there is more than 1,500 square feet of indoor floor area on any floor including the basement, there shall be an additional fire extinguisher with a minimum 10ABC rating for each additional 1,500 square feet of indoor floor area.Rep. from Jawco Fire service charged two extinguisher. [The fire extinguishers throughout the building will be checked monthly by the Director or Assistant Director to ensure no fire extinguishers are undercharged. Documentation shall be kept. (CHG 8/6/13)] 07/30/2013 Implemented
2390.124(5)The Record for Individual #1 admission date 2/14/13, did not include a physical.Each client's record must include the following information: (5) Physical examinations.Physical was received via fax during the inspection. Memo to rehab to make sure all documentation received prior to individuals starting in program. [The Director or Assistant Director will audit all current individuals records by 9/1/13 to ensure that documentation of a physical examination is in each individuals record. (CHG 8/6/13)] 07/29/2013 Implemented
SIN-00242597 Renewal 04/09/2024 Compliant - Finalized
SIN-00223537 Renewal 05/02/2023 Compliant - Finalized
SIN-00187381 Renewal 05/13/2021 Compliant - Finalized
SIN-00160173 Renewal 07/30/2019 Compliant - Finalized
SIN-00139731 Renewal 08/14/2018 Compliant - Finalized
SIN-00099670 Renewal 08/18/2016 Compliant - Finalized