Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225637 Renewal 06/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(g)Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. The fire drills completed from June 2022 through June 2023 did not include or indicate if the individuals evacuated to a designated meeting place outside the building or within the fire safe area during each of the fire drills completed during that timeframe.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The fire drill form has been updated to reflect the question, did all participants meet at the designated spot? yes or no. 06/29/2023 Implemented
2380.111(a)Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had a physical examination on 1/10/22, and their next one was completed on 3/29/23. Individual #2 had a physical examination completed on 2/24/22, and their next one was completed on 3/29/23. This exceeds the requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.We have revised the physical form for it to hopefully be less complicated for the medical providers. We have also sent letters to the families and Individuals about not be able to attend the ATF if the physical is late or not fully completed. These letters were mailed out today. 06/29/2023 Implemented
2380.111(c)(5)Tuberculin skin testing with negative results every 2 years. Individual#1 had a Tuberculin skin testing with negative results on 4/1/22, but there is no record or documentation of them having one prior.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.We have revised the physical form for it to hopefully be less complicated for the medical providers. We have also sent letters to the families and Individuals about not be able to attend the ATF if the physical is late or not fully completed. These letters were mailed out today. 06/29/2023 Implemented
2380.111(c)(6)Individual #3's physical examination dated 6/1/22 did not include specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.We have revised the physical form for it to hopefully be less complicated for the medical providers. We have also sent letters to the families and Individuals about not be able to attend the ATF if the physical is late or not fully completed. These letters were mailed out today. ((Individual #3's physical was returned to physician to gather missing information -CH 7/27/23)) 06/29/2023 Implemented
2380.111(c)(7)Individual #3's physical examination dated 6/1/22 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.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.We have revised the physical form for it to hopefully be less complicated for the medical providers. We have also sent letters to the families and Individuals about not be able to attend the ATF if the physical is late or not fully completed. These letters were mailed out today. ((Individual #3's physical was returned to physician to gather missing information -CH 7/27/23)) 06/29/2023 Implemented
2380.111(c)(9)Individual #3's physical examination dated 6/1/22 did not include allergies or contraindicated medication for the individual.The physical examination shall include: Allergies or contraindicated medication.We have revised the physical form for it to hopefully be less complicated for the medical providers. We have also sent letters to the families and Individuals about not be able to attend the ATF if the physical is late or not fully completed. These letters were mailed out today. ((Individual #3's physical was returned to physician to gather missing information -CH 7/27/23)) 06/29/2023 Implemented
2380.111(c)(10)Individual #3's physical examination dated 6/1/22 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.We have revised the physical form for it to hopefully be less complicated for the medical providers. We have also sent letters to the families and Individuals about not be able to attend the ATF if the physical is late or not fully completed. These letters were mailed out today. ((Individual #3's physical was returned to physician to gather missing information -CH 7/27/23)) 06/29/2023 Implemented
2380.113(a)A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #1's date of hire is 3/30/22 and their physical examination was completed on 4/11/22. Staff #2's date of hire is 10/2/22 and their physical examination was completed on 10/7/22.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.All new staff will not start orientation or be on site until the physical is completed and submitted to HR. A date of hire will then be selected. 06/29/2023 Implemented
2380.181(e)(13)(ii)Individual #1's assessment dated 8/22/22 and Individual #2's assessment dated 3/10/23 did not address the individual's progress over the last 365 calendar days in the area of motor and communication skills.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Director and Program Specialist discussed the regulation and what the inspectors will be looking for in the progress section. We reviewed which sections. The program Specialist will be dropping down under neath each section and adding the progress for the year. 06/29/2023 Implemented
2380.181(e)(13)(iii)Individual #1's assessment dated 8/22/22 and Individual #2's assessment dated 3/10/23 did not address the individual's progress over the last 365 calendar days in the area of personal adjustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Director and Program Specialist discussed the regulation and what the inspectors will be looking for in the progress section. We reviewed which sections. The program Specialist will be dropping down under neath each section and adding the progress for the year. 06/29/2023 Implemented
SIN-00206356 Renewal 06/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)The annual physical examination for Individual #2 was late. The Individual's previous physical examination occurred on 2/02/2021, and the current physical examination on 4/05/2022.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.A letter has been distributed to all Individuals and family members stating the importance of the physical and additional communications and meetings will be held if the physical is late or not being scheduled. 08/19/2022 Implemented
2380.111(c)(5)Individual #2 received Tuberculin skin testing late. The Individual had Tuberculin skin testing on 12/09/2019, then not again until 4/05/2022The 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.In the letter that was sent to Individuals and families states that all highlighted sections need to be completed on the fiscal. 08/19/2022 Implemented
2380.21(v)Individual #1 was informed of their individual rights as part of the Individual's admission process on 4/01/2022 but a copy was not signed and retained in the Individual's record.The 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.The Individual Rights form has been signed by the Individual on 6/14/2022. 06/14/2022 Implemented
SIN-00166293 Renewal 12/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #3's current physical states that she last received her TDaP immunization on 05-14-01.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Director of Program Services has developed a checklist for individuals physicals to assist the Program Specialist in the regulations that need to be completed on the physicals. A letter was also developed if the physical needs to be returned. The letter will have check marks next to the areas that need to be completed with a due date for the return. 01/03/2020 Implemented
2380.111(c)(5)Individual #2 does not have a current TB test. Her last TB test was completed on 05-15-17. Individual #3 was admitted on 11-24-17 and the only TB test on file is from 09-05-18, which was ten months after she started in the program.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.The Director of Program Services has developed a checklist for individuals physicals to assist the Program Specialist in the regulations that need to be completed on the physicals. A letter was also developed if the physical needs to be returned. The letter will have check marks next to the areas that need to be completed with a due date for the return. 01/03/2020 Implemented
2380.111(c)(9)Individual #2's physical form does not address if she has any allergies.The physical examination shall include: Allergies or contraindicated medication.The Director of Program Services has developed a checklist for individuals physicals to assist the Program Specialist in the regulations that need to be completed on the physicals. A letter was also developed if the physical needs to be returned. The letter will have check marks next to the areas that need to be completed with a due date for the return. 01/03/2020 Implemented
2380.113(a)Staff #1's physical was completed after she started. Her start date was 05-06-19 and her physical was completed on 05-10-19.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.The Program Services Director and the HR Manager will ensure that staff are not starting on the ATF program until their physical is completed. The Director will note if staff start at the main office with training and not starting at the ATF location before the physical is completed. 01/02/2020 Implemented
2380.113(c)(2)Staff #1's initial TB test was administered after she started. Her start date was 05-06-19 and her TB was administered on 05-10-19.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.The Program Services Director will ensure that any new staff will have a TB test and completed physical before starting/ The Director will work with the HR Manager on scheduling the physical before the start date of any new employee. 01/02/2020 Implemented
2380.181(a)Individual #4's initial assessment was late. He was admitted on 06-27-19 and his initial assessment was not completed until 09-02-19, which is beyond the required 60-day window after admission.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 Specialist were retrained on the regulation about the 60 day assessment and this it is required within 60 calendar days. 01/03/2020 Implemented
SIN-00147606 Renewal 01/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The temperature of the hot water, measured at one of the bathroom sinks, was 126.5 degrees Fahrenheit.Hot water temperatures in areas accessible to individuals may not exceed 120°F.An new digital thermometer was bought for the ATF for the Program Manager to check the water temperature monthly. ((Water Temperature currently reads 120F -CH 2/22/2019)) 01/21/2019 Implemented
2380.89(c)The fire drill record from the fire drill conducted on 6/18/18 did not document if the fire alarm was operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.The Program Manager was retrained to make sure that all fire drill forms are filled out completely. 01/16/2019 Implemented
2380.111(c)(3)Individual #2 was overdue for a TD or Tdap immunization which is recommended by the Centers for Disease Control to be administered every ten years. Individual #2's most recent Tdap was administered 9/05/07.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Program Specialist and Program Director will continue to work with families to ensure that physicals are completed correctly and that all immunizations are up to date. ((PIP has reached out to the family of Individual #2 and requested the required information -CH 2/22/2019)) 01/16/2019 Implemented
2380.173(1)(iv)Individual #1's record did not document the individual's religious affiliation.Each individual's record must include the following information: Personal information including: Religious affiliation.Program Specialist and Program Manager will make sure that all Personal information is completed and will insert an N/A if there is not religious affiliation. ((PIP has updated all assessments with the required information -CH 2/22/2019)) 01/17/2019 Implemented
2380.181(e)(12)The assessment for Individual #1 dated 6/29/18 did not contain recommendations for specific areas of training, vocational programming, and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Program Specialist will be retrained to make sure that assessment have noted on them the recommendations for the areas training, vocational programming and working towards community integrated employment. ((All individual assessments will be reviewed and updated with the required information by 4/30/19 -CH 2/22/2019)) 02/13/2018 Implemented
SIN-00126178 Renewal 01/22/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1 had fire safety training on 8/26/2016. She didn't have it again until 11/27/2017, which exceeds the annual requirement. Staff #2 had fire safety training on 11/10/2016. She didn't have it again until 12/26/2017, which exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).Program Director will ensure that Staff have the annual fire safety training in October of this year. 10/31/2018 Implemented
2380.84A fire safety inspection was completed on 2/15/2016. It wasn't completed again until 1/18/2018, which exceeds the annual requirement.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.Program Director will make sure that she calls the Fire safety expert before 1/8/2019 for the next annual requirement. 01/08/2019 Implemented
2380.91(a)Individual #1 had fire safety training on 10/3/2016. He didn't have it again until 1/2/2018, which exceeds the annual requirement. Individual #2 had fire safety training on 12/1/2016. As of 1/23/2018, she hasn't had fire safety training again, which exceeds the annual requirement.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Program Director will make sure that all participants have Fire Safety in October for the 2380 regulations. 10/31/2018 Implemented
2380.186(a)Individual #2 had ISP Reviews on 4/7/17, 7/26/17 and 10/26/2017. The time frame between 4/7-7/26/2017 exceeds the 3 month requirement.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.Program Director will reteach Program Specialist and make sure that ISP reviews for quarterlies will not exceed three months. The Program Specialist will review with the individual before the three month time frame and then will go over with team if they would like to still meet. 02/16/2018 Implemented
SIN-00107186 Renewal 02/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1 was admitted to program on 5/1/2016. As of inspection date, the only available copy of his fire safety training was dated 10/19/2016, which is 4 months late. An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.The Program Specialist will ensure all new individuals have Fire Safety upon admission to the ATF. 03/08/2017 Implemented
2380.111(a)Individual #1 was admitted to program on 5/1/2016. The physical exams on file are dated 2/25/2015 and 12/20/2016. The 2015 exam exceeds 1 year prior to admission & the 2016 exam is almost 8 months late.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialist will obtain a copy of a physical before the individual starts and then will obtain a yearly physical there after. The Program Specialist will keep all documentation available on attempts to obtain the physical. 03/08/2017 Implemented
2380.111(c)(2)Individual #1's physical exam did not include this section.The physical examination shall include: A general physical examination.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(3)Individual #1's physical exam did not include this section.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(4)Individual #1's physical exam did not include this section.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(5)Individual #1's physical exam did not include this section. On individual #3's physical exam, this section was not filled in by her doctor.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.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(6)Individual #1's physical exam did not include this section. On Individual #2's physical exam, this section was not filled in by his doctor. The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(7)Individual #1's physical exam did not include this section. On Individual #3's physical exam, this section was not filled in by her doctor.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.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(8)Individual #1's physical exam did not include this section.The physical examination shall include: Physical limitations of the individual.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(9)Individual #1's physical exam did not include this section.The physical examination shall include: Allergies or contraindicated medication.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(10)Individual #1's physical exam did not include this section. On Individual #2's and Individual #3's physical exams, this section was not filled in by their doctors.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.111(c)(11) On Individual #1's physical exam dated 12/20/2016 it states "As Tolerated" in the dietary section. Individual #1 is on a pureed diet. The physical examination shall include: Special instructions for an individual's diet.Partners In Progress is working with the AE in using a physical form that covers all regulations. PIP has also highlighted the required areas on the physical for the physicians to complete. We have also developed a cover letter to be attached to the physical. 03/08/2017 Implemented
2380.113(a)Staff #1 was hired on 9/19/2016. She didn't have a physical exam until 9/22/2016.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.All new hires will have a physical prior to starting work and two years there after 03/08/2017 Implemented
2380.113(c)(2)Staff #1 was hired on 9/19/2016. She didn't have a TB test until 9/23/2016.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.All new hires will have their TB test completed before they start work and then every two years after. 03/08/2017 Implemented
SIN-00087386 Initial review 12/22/2015 Compliant - Finalized