Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231617 Renewal 11/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)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. Individual #1 had a Tuberculin skin testing with negative results on 5/13/21 and their next one did not occur until 7/13/23. This exceeds the requirement.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.Individuals will have Tuberculin skin testing with negative results every two years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Individuals Tuberculin test was done but was late. 12/05/2023 Implemented
2380.111(c)(7)Individual #2's physical examination dated 9/11/23 did not include an assessment of the individual's health maintenance needs. This section of the form 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.DES contacted the individual¿s residential Program Director and requested that they have the individual¿s health assessment section of the 9/11/23 physical form completed and then return the completed physical form to DES. 12/06/2023 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 10/6/23 and Staff #1's physical examination is dated 10/11/23.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 employees hired by DES will have a physical examination within 12 months prior to employment and every 2 years thereafter 12/06/2023 Implemented
2380.113(c)(2)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. Staff #2 had a negative Tuberculin skin testing on 10/22/21 as the results were 0mm, and their next reading on 10/16/23 noted 6 mm. Mantoux test is positive (an induration of 5 mm or larger, regardless of history) assess for active TB. According to the CDC, a repeat PPD Test is considered positive if induration is greater than ten mm and has increased by at least six mm compared with the previous test. There was no chest x ray documentation in the file as well.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.Staff will have a Tuberculin skin test with negative results every 2 years; or if the test is positive, an initial chest X-ray with results noted. The employee contacted their physician and got documentation that the Tuberculin test done on 10/16/23 was negative (Attachment A). Employee also followed up with a chest x-ray has recommended at licensing, the results of the x-ray were also negative. (Attachment B). 12/06/2023 Implemented
SIN-00214470 Renewal 11/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #3 has a documented date of admission of 8/8/22. The physical submitted for review was dated 9/30/22. There was no documentation to support that a physical had been completed in the 12 months prior to admission as required.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Provider¿s Plan of Correction: Individual #3 began attending Developmental Education Services CPS program on 8/8/22, while she did not have a physical within 12 months prior to her admission date, she now has a completed physical on file dated 9/30/22 and will have an examination annually. 12/09/2022 Implemented
SIN-00198956 Renewal 11/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)An unlabeled spray bottle was found in the maintenance closet with an unknown solution inside.Poisonous materials shall be stored in their original, labeled containers.Plastic spray bottle contained soap and water, contents were emptied into the sink in the maintenance room at the time of inspection. Empty unlabeled spray bottle was disposed of. 11/10/2021 Implemented
2380.39(c)(1)Staff #1 did not complete annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 7/01/2020 to 6/30/2021 training year.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 #1 completed training in person centered practices (Appropriate and Creative Supports and Services) 11/3/21, community integration (Inclusion: Helping or Hovering) 11/23/21, individual choice (Acknowledging Self-Determination in Supporting Participants) 1/4/22 and supporting individuals to develop and maintain relationships (Nonverbal Communication: Myths and Misconceptions) 2/1/22. 02/05/2022 Implemented
2380.39(c)(2)Staff #1 did not complete annual training in the prevention, detection and reporting of abuse during the 7/01/2020 to 6/30/2021 training year.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.Staff #1 completed training in all components of 2380.39(c)(2). Addressing Day to Day Risks with Tram (12/14/21), Abuse: Detection, reporting and Prevention of Abuse, Suspected Abuse and Alleged Abuse, 11/5/21 and Act 31/Act 126 Recognizing Child Abuse and Mandated Reporting on 11/30/21. 12/01/2021 Implemented
2380.39(c)(3)Staff #1 did not complete annual training in individual rights during the training year 7/01/2020 to 6/30/2021.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #1 completed training in individual rights (AS217: Self Determination) 3/1/22. 03/01/2022 Implemented
2380.39(c)(5)Staff #1 did not complete annual training in the safe and appropriate use of behavior supports during the 7/01/2020 to 6/30/2021 training year.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 #1 completed training in the safe and appropriate use of behavior supports (Teaching Coping & Self-Regulation Skills) 3/1/2022. 03/01/2022 Implemented
SIN-00119829 Renewal 09/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(f)Staff #1 had no annual fire safety training in 2016.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).: Staff #1(A.G.) was out on medical leave when DES held annual fire safety training and it was not recognized when she returned to work that she needed the training. As of 9/18/17 DES modified the form staff use to track their training hours. To help DES Admin., and DES staff track what annual trainings are still needed a separate page has been created (see attachment A1) to make staff more aware of all annual trainings that they need to complete within the established training year. This will allow staff, when checking training hours, to easily recognize if they need to complete a mandatory training. DES staff are to now also now sign the annual consumer fire safety training documentation form as back up documentation that they received annual fire safety training. DES held their 2017 annual fire safety training on 9/14/17 and staff person Staff person #1 (A.G) completed annual fire safety training on 9/14/17. See attached training documentation (attachment A2). Person responsible Carol Miller. Implemented
2380.111(a)Individual #1 and Individual #2 both had late physical exams, which are required annually. Individual #1 had a physical completed on 06/21/16, then not again until 07/13/17. Individual #2 had a physical exam completed 08/17/16, then not again until 09/11/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Both consumers while receiving their physical late did have then completed. Individual #1 was absent from DES and in the hospital for psychiatric care from 6/23/17 until 7/12/17. She was not permitted to return to program until 7/14/17 when she brought in a completed physical. As of 8/25/17 all consumers, their residential providers and families if applicable, received a letter (see Attachment A6) 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 time frames established by Chapter 2380 regulations. This suspension will continue until they provide documentation that they have had them completed. Person responsible, Carol Miller, Director of Adult Services. Implemented
2380.111(c)(5)Individual #2 had a late TB test, which is required every two years. She had a TB test on 08/27/14, then not again until 10/02/16.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.Individual #2 did have a TB completed although it was late. As of 10/18/17 all physical notification letters (Attachment A6) will include the date the consumer had their last TB test as a reminder when the consumer is due again for their next TB test. Person responsible, Carol Miller, Director of Adult Services. As of 8/25/17 all consumers, their residential providers and families if applicable, received a letter (Attachment A5) 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 time frames established by Chapter 2380 regulations. This suspension will continue until they provide documentation that they have had them completed. Person responsible, Carol Miller, Director of Adult Services. Implemented
2380.113(c)(3)The section on Staff #2's physical form adressing communicable diseases was left blank and not addressed at all.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.As of 10/18/17 DES has modified the staff physical form to include a place at the bottom for the person filing the physical to initial after reviewing the form to ensure all parts are completed (see attachment A3) Director of Adult Services, Carol Miller will be responsible for giving Staff person #2(MC) a form (see attachment A4) for her to take to her physician to fill out, sign and date addressing communicable diseases as per 2380.113(c). Completion date 10/18/17. Staff person #2 (MC) will be responsible for having the paperwork completed by her physician and returned to DES by 11/1/17. If the completed paperwork is not received by 11/1/17 staff person #2(MC) will be removed from the substitution list until she returns completed paperwork. Implemented
SIN-00097254 Renewal 08/11/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(d)On this date, individual 1 was unable to evacuate within the 2 1/2 minutes during the fire drill. Individual 1 sat down on the floor and refused to evacuate for the first 2 minutes of the drill. Then he got up and slowly exited the building in 2 minutes and 46 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Since the licensing inspection on August 11, 2016 Consumer #1 and consumers and staff from DES Stroudsburg attended a Fire Safety Training presented by a Risk Management Specialist from Brown and Brown Insurance on September 14, 2016. (See attachment #1) This training included (but was not limited to) education about the importance of evacuating in a fire and the DES evacuation procedures, including the location of evacuation exits, the need to exit quickly and safely and the location of the designated meeting place. A fire drill was held on September 21, 2016 with 37 consumers and 10 staff present including consumer #1. Everyone evacuated the building in 1 minute and 22 seconds. (See attachment #2) Going forward, DES will continue to emphasize to all consumers the need to exit quickly in response to the fire alarm. Any fire drills not meeting the 2 1/2 minute time period will be documented with the reason. The DES team will resolve the issues for the slower time, then, by the end of the month, hold the fire drill again to ensure the 2 1/2 minute evacuation time is met. 10/04/2016 Implemented
SIN-00160780 Renewal 08/08/2019 Compliant - Finalized
SIN-00138203 Renewal 08/14/2018 Compliant - Finalized
SIN-00081808 Renewal 08/06/2015 Compliant - Finalized
SIN-00070219 Initial review 10/21/2014 Compliant - Finalized
SIN-00049654 Renewal 04/30/2013 Compliant - Finalized
SIN-00048982 Renewal 04/30/2013 Compliant - Finalized