Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230496 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)At the time of inspection there was a long cabinet in the back program room with misc. items and program supplies. There were two broken drawers within this cabinet. The one drawer was not able to be opened. The second drawer was able to be opened with a forceful pull, however, was off the track.Floors, walls, ceilings and other surfaces shall be in good repair.A maintenance request was put in to repair the drawers. The cabinet drawers were unable to be repaired so they were drilled closed on 9/28/23 so no one could open them, and they now look like a false front on the cabinet. 09/28/2023 Implemented
SIN-00212743 Renewal 10/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.126(a)(11)The Medication Administration Record (MAR) for Individual #1 did not contain a diagnosis or purpose for the medication Carbamazepine which is prescribed for the Individual.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1¿s MAR was corrected. Individual takes Carbamazepine for seizures. Epilepsy was removed from the diagnosis section and seizures was added in the diagnosis section of the MAR as the purpose for the Carbamazepine. 10/25/2022 Implemented
SIN-00198957 Renewal 11/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.39(c)(1)The annual training hours specified in subsections (a) and (b) for staff #2, staff #3 and staff #4 did not include training in the areas of person-centered practices, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff #2, #3, #4 completed all requirements in this area. Person Centered Practices (Appropriate and Creative Supports and Services) was completed by staff #2 on 11/19/21 and by staff #3 and #4 on 11/8/21. Community Integration (Inclusion, Helping or Hovering) was completed by staff #2 on 11/9/21, by staff #3 on 11/23/21 and staff #4 on 11/22/21. Individual Choice (Acknowledging Self Determination in Supporting Participants) was completed by staff #2 on 1/12/22, staff #3 on 1/4/22 and staff #4 on 1/4/22. Supporting Individuals to Develop and Maintain Relationships (Non Verbal Communication, Myths and Misconceptions) was completed by staff #2 and #3 on 2/2/22, and staff #4 on 2/24/22. 02/24/2022 Implemented
2380.39(c)(2)The annual training hours specified in subsections (a) and (b) for staff #1, staff #2, staff #3 and staff #4 did not include training in the areas of 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.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.Addressing Day to Day Risks with Team was completed by Staff #1, #2, #4 on 12/27/21, Staff #3 completed on 1/3/22. Act 31/Act 126 Recognizing Child Abuse and Mandated Reporting on was completed by Staff #1, #3, #4 on 12/27/21 and by Staff #2 on 12/28/21. Staff #1, #2, #3, #4 completed Abuse: Detection, Reporting and Prevention of Abuse, Suspected Abuse and Alleged Abuse on 3/4/22. 03/04/2022 Implemented
2380.39(c)(3)The annual training hours specified in subsections (a) and (b) for staff #2, staff #3 and staff #4 did not include training in the areas of Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #2, #3, #4 completed training in Individual Rights. Staff # 2, #3, #4 completed (The Right to Eat to Many Donuts and Take a Nap: Self Determination for ID/DD) on 3/1/22. 03/01/2022 Implemented
2380.39(c)(5)The annual training hours specified in subsections (a) and (b) for staff #2, staff #3 and staff #4 did not include training in the area of the safe and appropriate use of behavior supports if the person works directly with an individual.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 an individual.Staff #3 completed training in the safe and appropriate use of behavior supports (Targeting Behavioral Needs) on 5/14/21, and Staff #4 completed it on 1/7/21. Staff #2 will complete a training in this area by 6/30/22. 03/30/2022 Implemented
2380.39(c)(6)The annual training hours specified in subsections (a) and (b) for staff #1, staff #3 and staff #4 did not include training in the area of the individual plan if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The policy at the time of licensing for training staff in the implementation of the individual plan was to review and train all staff in each individuals plan when it was updated annually or modified. Staff then signed off and dated that they had reviewed and had training on each person¿s plan. As part of the plan of correction DES Administration, in addition to this process, will also require all staff to complete the online MYODP Implementation of the Individual Plan when it becomes available. 06/30/2022 Implemented
SIN-00156815 Renewal 06/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1 had a late TB test. He had one completed on 03-25-16, then not again until 04-25-18.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.Current Policy: For those consumers who do not receive their tuberculin test at the same time as their physical DES sends out a tuberculin test notification letter. This letter goes to the consumers residential provider, and family member, if applicable, 3 months prior to the date they are due for their tuberculin test. The notification letter includes the date of the last tuberculin test, the date the test needs to be completed by, and the date the form needs to be returned to DES. Corrective Action(s) to address citation: J. P. will be due for his next Tuberculin test on 4/25/20. He had his last physical on 3/4/19. When he is due for his annual physical in March of 2020 DES will recommend that he have his Tuberculin test done then so that it will coincide with his physical and there will be less chance of his parents not having the tuberculin test done on time. For any consumer who does not have the TB testing on time DES will suspend the consumer until the testing is completed and the documentation provided to DES. 06/24/2019 Implemented
SIN-00134640 Renewal 05/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(11)Individual #1 is on a soft, chopped diet with alternate sips of liquid in between. Her physical exam dated 9/7/2017 states None' for special diet instructions. Individual #2 needs his food cut in small pieces & requires encouragement to drink between each bite. His physical exam dated 4/4/2018 states no restrictions for special diet instructions.The physical examination shall include: Special instructions for an individual's diet.West End Corrective Action Plan 2018 2380.55 Regulations Chapter 2380.111(c)11 Special Diet Correction Required: The physical exam shall include: Special Instructions for an individual¿s diet. Immediate plan of correction Individual #1 resides with his mother. Individual #2 will send home his most recent physical form, and request that his mother have the physician fill in the special instructions for diet information that is noted in the ISP. Individual #1 resides in a community living home operated by Fitzmaurice Residential Services. Individual #2 will send her most recent physical to the Program Manager, and request that they have the physician fill in the special instructions for diet information that is noted in the ISP. Completion Date: 5/30/18 Person Responsible: Carol Miller, Director of Adult Services Plan to Prevent Future Occurrences Currently the Individual #2 Physical form has a section captioned; Physical Limitations, Restrictions. Special Instructions for Diet, Exercise or Activities. Individual #2 has modified this form so that Special Instructions for Diet is broken out into its own section. See attachment A. Individual #2 sends out a physical notification letter along with a Individual #2 Physical Form to the consumer, to their residential provider, and family member if applicable, 3 months prior to the date they are due for their physical. The notification letter includes the date of last year¿s physical, the date the completed, signed physical form needs to be returned to Individual #2, and the frequency for TB testing and immunizations. A paragraph will be added with regulation (c)11 added. See attachment B. Completion Date: 5/30/18 Person Responsible: Carol Miller, Director of Adult Services As each physical is completed in the coming year, Individual #2 will review the Special Instruction for Diet section and compare it to the information in the ISP. If there is special diet information in the ISP not noted on the physical form Individual #2 will send the physical back to either the consumer¿s family or residential provider wit 05/30/2018 Implemented
SIN-00114467 Renewal 06/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #1's TB test was late. It was completed on 02-18-15 then not again until 04-24-17.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.DES sends out a physical notification letter along with a DES Physical Form to the consumer, residential provider, and family member if applicable, 3 months prior to the date the physical exam is due. As of 8/23/17 all physical notification letters will include the date the consumer had their last TB test as a reminder when the consumer is due again. The Director of Adult Services is responsible for completion. As of 9/1/17 all consumers, residential providers and families as applicable will receive a letter informing them that as a result of the recent licensing DES will suspend any consumer who does not have their physical, TB test, or immunization completed within the regulated time frames. This suspension will continue until they provide documentation that they have had them completed. The Director of Adult Services is responsible for completion. 08/21/2017 Implemented
SIN-00093841 Renewal 06/23/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(c)Coliform water testing was not competed every 3 months at the program. Coliform testing was completed on 5/1/15 and not again until 8/21/15 (20 days late); 11/10/15; 12/1/15; 1/11/16; and not again until 5/4/16 (1 month late).A facility that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Developmental Education Services Brodheadsville site had been contracting with Microbac Laboratory for scheduled automatic on site total coliform water testing since 2014. Microbac laboratory had completed the onsite Total Coliform testing every 3 months since 2014. A water test was due in April of 2016, but Microbac did not come to do the test until May 5, 2106. DES Program Specialist Carol Miller contacted Microbac when the results of the test were received on May 10, 2016, to find out why the test was not done in April 2016. Microbac said that they had never guaranteed 3 month testing, and in fact, were no longer going to de doing onsite testing (See attachment B). C. Miller then contacted Prosser Laboratory in Effort and contracted with them to begin automatic, scheduled, on site Total Coliform water testing, bi-monthly at the DES West End site beginning in July 2016 (see attachment). To ensure compliance with PA ODP Chap, 2380 Regulation 59 (c), DES contracted with Prosser laboratories for automatic scheduled onsite Total Coliform water testing bi-monthly instead of every 3 months. If the DES Program Specialist does not receive the completed results of the water test by the end of the second month this will allow time for the DES to contact Prosser laboratory to schedule a test and still have a Total Coliform test done within the 3 months required by PA ODP Chapter 2380 regulation 59 (c). 06/21/2016 Implemented
2380.186(e)Individual 1¿s team was not given the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Developmental Education Services added to the ISP signature page a statement informing the Plan Team members that they have the option to decline the ISP Review documentation, and may do so by checking the box next to their signature. This will let the DES Program Specialist know they have declined the ISP Review documentation (See attachment A). All DES Program Specialists will begin using this new signature form at ISP meetings, beginning on 9/13/2016. Anyone declining by checking the box will not be sent ISP Review documentation. To monitor compliance, prior to any ISP Review documentation being sent to Plan Team members, a DES Program Specialist will review the carbon copy (CC) section to make sure no one who had declined is listed and then date and initial the carbon copy (CC) section. 09/13/2016 Implemented
SIN-00077519 Renewal 05/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff #1 had a physical examination on 04/28/2011 and again on 04/03/2013 . As of 05/19/2015 staff #1 did not have another physical examination since 04/03/2013 which exceeds the two year time frame.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.DES recognizes a breakdown in the current system of staff notification for timely submission of physical examinations. A new policy/procedure outlines the responsibility of each program director/manager to notify her/his employee at two months prior to the examination's due date; then again at one month prior to the due date and requesting the date of the employee¿s medical appointment. If the employee fails to submit a completed and signed examination by the due date, the employee is suspended without pay for five (5) working days, for a final chance at compliance. If, at the end of the five (5) working days, the employee is still not compliant, DES will remove the employee from the active roster and consider the employee¿s position forfeited for failure to adhere to regulatory standards. 07/01/2015 Implemented
SIN-00164992 Change in Location Capacity 06/06/2019 Compliant - Finalized
SIN-00076161 Change in Location Capacity 03/23/2015 Compliant - Finalized
SIN-00061640 Renewal 04/08/2014 Compliant - Finalized
SIN-00046929 Renewal 04/30/2013 Compliant - Finalized