Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216718 Renewal 12/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill held 4/28/2022 did not include the exit route used. This section was left blank. The fire drill held 3/30/22 had "outside in front" as the exit route used.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 or smoke detector was operative. Fire Drill's will be reviewed by Manager's monthly as they are completed to ensure that 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 or smoke detector was operative. 01/30/2023 Implemented
6400.52(c)(1)Executive Director/Chief Executive Officer Designee #1, date of hire 12/6/84, and Direct Service Worker #2, date of hire 5/1/18, did not receive training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during training year 1/1/21-12/31/21.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.Executive Director/Chief Executive Officer Designee #1, date of hire 12/6/84, and Direct Service Worker #2, date of hire 5/1/18, did receive training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during training year 1/1/21-12/31/21. This was completed however it appears that the documentation showing that this was done was not clear. 02/28/2023 Implemented
6400.52(c)(3)Executive Director/Chief Executive Officer Designee #1, date of hire 12/6/84, and Direct Service Worker #2, date of hire 5/1/18, did not receive training in Individual rights during training year 1/1/21-12/31/21.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Executive Director/Chief Executive Officer Designee #1, date of hire 12/6/84, and Direct Service Worker #2, date of hire 5/1/18, did receive training in Individual rights during training year 1/1/21-12/31/21. These trainings were completed, however, the wording was not satisfactory as to what our training was classified under. 02/28/2023 Implemented
SIN-00168224 Renewal 12/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records were not available for the fire drills held from 1/1/19 to 9/30/19.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 or smoke detector was operative. UCIP's office at 17999 Cussewago Road, Meadville PA 16335. experienced a fire on 9/18/19. Records of completed monthly fire drills for the Blooming Valley location were kept in this office and were destroyed. Program Specialist Matt Morian has records of fire drills done on 9/30/19, 10/15/19, 11/26/19 and 12/18/19. Program Specialist Matt Morian will continue to complete and document fire drills monthly according to what is outlined in the regulations set by ODP. [Immediately and upon hire, the CEO or designee shall educate all staff persons responsible for conducting, documenting and maintaining records on the procedures of maintaining written fire drill records to include all required information. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
6400.141(a)Individual #1 does not have a physical examination.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. [Individual #1] 's Primary Care Physician was contacted by Program Specialist Matt Morian and documentation of Richard's physical form 8/6/19 was recovered. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current physical examination. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
6400.141(c)(6)Individual #1 does not have Tuberculin testing.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 #1]'s Primary Care Physician office was contacted by Program Specialist Matt Morian and documentation of Richard's TB test and results were recovered. [Individual #1]'s TB test was administered on 8/3/18. Results were read on 8/6/18 and were negative. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
6400.142(a)Individual #1 does not have a dental examination.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. [Individual #1]'s original dental exam was lost in facility fire on 9/18/19. Program Specialist Matt Morian contacted Medical provider and received [Individual #1]'s dental exam that was done 7/29/19. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
6400.151(a)Direct Service Worker #1 does not have a physical examination. 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Michelle Bly's physical documentation was recovered by HR Director Patti Capron. Michelle has a physical completed on 3/13/18. [Immediately, the CEO or designee shall audit all staff persons' records to ensure all staff persons have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
6400.151(c)(2)Direct Service Worker #1 does not have Tuberculin testing. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if 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, licensed physician's assistant or certified nurse practitioner. Michelle Bly's TB results were recovered from TB Administrator at Vernon Place Medical facility. The test was administered on 3/13/18. Results were read on 3/15/18 and were negative.[Immediately, the CEO or designee shall audit all staff persons' records to ensure all staff persons have a current physical examination including Tuberculin testing. Missing information shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
6400.181(a)Individual #1 does not have an assessment. 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. Due to [Individual #1]'s original assessment being lost in facility fire on 9/18/19 an additional assessment was completed on 12/23/19 by Program Specialist Matt Morian and sent to [Individual #1]'s team. [Immediately, the CEO or designee shall audit all individual's records to ensure all individuals have a current assessment. Missing assessments shall be immediately obtained or completed as required. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
6400.163(h)Triamcinolone Acetonide .1% cream, apply sparingly topically 2 times a day for 14 days prescribed to Individual #1 was discontinued on 10/31/19; remained in Individual #1's medication storage box.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Medication was removed from the home on 12/19/19 and stored at the UCIP office building until UCIP Nurse Holly Cardy disposed of the medication on 1/7/20. [Immediately and continuing at least monthly, the CEO or designee shall audit all individual medications, medications administration records and physicians' orders to ensure all individuals are administered medications prescribed and documented as required and discontinued or expired medications are destroyed in a safe manner according to Federal and State statutes and regulations. Immediately, upon hire and continuing at least annually, the CEO or designee shall educate all staff person responsible for medication administration of the agency's policies and procedures for ensure prescription medications that are discontinued or expired are destroyed in a safe manner according to Federal and State statutes and regulations. Documentation of trainings shall be kept as required. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
SIN-00088526 Renewal 01/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 1/12/16, there was an unlocked cabinet beside the toilet located in the first floor bathroom that contained toilet cleaner with bleach and "Scrubbing Bubbles" cleaner. Both items indicate to contact poison control if ingested. Individual #1 is not assessed to safely avoid or use poisonous materials as per the assessment completed on 1/2/16.Poisonous materials shall be kept locked or made inaccessible to individuals. Program Specialist while doing their monthly monitoring of the house will check to make sure all poisonous materials are locked. They will then turn that monitoring form into their Manager for review to make sure all areas of concerns were addressed. [A lock was put on the cabinet beside the toilet located in the first floor bathroom on 1/12/16. Immediately, program specialist will complete an on-site monitoring of all community homes to ensure poisonous materials are kept locked and made inaccessible to individuals. Within one month of receipt of the plan of correction, all direct service workers working in community homes will be trained as to the regulation and procedures to ensure all poisonous materials are kept locked or made inaccessible to individuals in community homes. Documentation of all on-site monitoring's and trainings shall be kept. (AS 5/4/16)] 04/21/2016 Implemented
SIN-00096982 Renewal 01/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 1/12/16, there was an unlocked cabinet beside the toilet located in the first floor bathroom that contained toilet cleaner with bleach and "Scrubbing Bubbles" cleaner. Both items indicate to contact poison control if ingested. Individual #1 is not assessed to safely avoid or use poisonous materials as per the assessment completed on 1/2/16. Poisonous materials shall be kept locked or made inaccessible to individuals.4.21.16 Program Specialist while doing their monthly monitoring of the house will check to make sure all poisonous materials are locked. They will then turn that monitoring form into their Manager for review to make sure all areas of concerns were addressed. [A lock was put on the cabinet beside the toilet located in the first floor bathroom on 1/12/16. Immediately and continuing at least monthly, program specialist will complete an on-site monitoring of all community homes to ensure poisonous materials are kept locked and made inaccessible to individuals. Within one month of receipt of the plan of correction, all direct service workers working in community homes will be trained as to the regulation and procedures to ensure all poisonous materials are kept locked or made inaccessible to individuals in community homes. Documentation of all on-site monitoring's and trainings shall be kept. (AS 5/4/16)] 04/21/2016 Implemented
SIN-00129021 Renewal 02/08/2018 Compliant - Finalized
SIN-00058326 Renewal 12/17/2013 Compliant - Finalized
SIN-00041225 Renewal 08/22/2012 Compliant - Finalized