Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00205369 Renewal 05/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical exam on 6/19/20 and their next physical exam occurred on 7/13/21. This exceeds the requirement.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialist will send out a letter reminding families/caregivers of physical due dates and requirements for the physical examination and stating the fact that services will be interrupted if required timelines are not met. (Attachment #1) 07/25/2022 Implemented
2380.111(c)(5)Individual #1had a Tuberculin skin testing with negative results on 4/18/19 and their next Tuberculin skin testing with negative results occurred on 7/15/21. 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.Program Specialist will send out a letter reminding families/caregivers of physical due dates and requirements for the physical examination (Including a negative TB skin test every two years or an initial chest X-ray with results if TB test is positive) and stating the fact that services will be interrupted if this does not happen. (Attachment #1) 07/25/2022 Implemented
2380.111(c)(9)Individual #1's physical exam dated 7/13/21 did not document their Allergies or contraindicated medication. Both of these section on the physical exam were left blank.The physical examination shall include: Allergies or contraindicated medication.Individual #1's physical was returned to the physician and allergies and contraindicated medications sections were completed and dated by PCP. (Attachment #3) 06/03/2022 Implemented
2380.111(c)(10)Individual #1's physical exam dated 7/13/21 did not document their medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank on the physical exam.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual #1's physical was returned to the physician and medical information pertinent to diagnosis and treatment in case of emergency section was completed and dated by PCP. (Attachment #3) 06/03/2022 Implemented
SIN-00188419 Renewal 05/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.39(c)(3)Staff #1 did not complete training in Individual Rights during annual training year 2020. **Some annual trainings missed due to COVID19 have been waived per Appendix K, but Individual Rights training is still required,The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #1 completed Individuals Rights training on 5/27/21, after the oversight was found during inspection on 5/25/21. Certificate of Achievement was received (Attachment #1). 06/21/2021 Implemented
2380.126(a)(7)Individual #1 is prescribed Acetaminophen 325mg. tab to be administered pro re nata (PRN) for minor pain, discomfort or fever. The medication administration record (MAR) and pharmacy label do not state a specific dose to be administered. The MAR and pharmacy label state that "1 or 2 tablets" should be administered with no criteria given for staff to determine whether to administer 1 tablet or 2 tablets. The medication dosage should be specific and determined by the prescriber, not the staff who administer it.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The residential provider was contacted and the received a new standing order from the physician stating Individual #1 should receive "Acetaminophen (Tylenol) 325 mg tabs ---give 2 tabs (650 mg) by mouth as needed for pain or temp greater than 100.5F every 4 hours. Call doctor for fever lasting 3 days or longer." This script (Attachment #3 A & B) was sent with an OTC bottle of 325 mg Tylenol tabs. Old blister pack of medications was returned to the group home. 06/21/2021 Implemented
SIN-00170239 Renewal 03/05/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a late annual physical examination. Individual #1's current physical examination occurred on 2/21/20, and the previous physical examination occurred on 10/29/18.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.An informational letter (Attachment #4) and blank physical form will be sent to program participants no later than two months prior to physical due date. If a completed physical is not returned, a reminder letter will be sent one month prior to physical due date. If the physical form, with all sections completed, is not received by the due date, and all attempts by the Program Specialist have been unsuccessful, services will be suspended after the 15 day grace period expires, until a completed physical is received. 03/20/2020 Implemented
2380.173(1)(ii)Individual #1's record did not include the following information: hair color, eye color and identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Emergency information for Individual #1 was updated to include hair color, eye color, and identifying marks (Attachment #3). Site Supervisor/Program Specialist and Program Manager will audit files for new admissions to ensure that paperwork is filled out correctly and completely. 03/20/2020 Implemented
2380.173(1)(iv)Individual #1's record did not include the individual's religious affiliation.Each individual's record must include the following information: Personal information including: Religious affiliation.Religious affiliation was added to Individual #1's emergency information sheet in her file (Attachment #2). Site Supervisor/Program Specialist and Program Manager will audit files for new admissions to ensure that all forms are completed correctly and completely. 03/20/2020 Implemented
2380.181(f)The program specialist did not provide Individual #1's assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. The assessment for Individual #1 was completed on 6/26/19 and provided to the individual plan team members on 6/26/19, which was 21 calendar days prior to the individual plan meeting held on 7/17/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Program Specialist will use the Skills Assessment Tracking Sheet (Attachment #1) to ensure that assessments are mailed at least 30 days prior to individual plan meetings. Site Supervisor and Program Manager will review tracking sheets to ensure compliance. 03/20/2020 Implemented
SIN-00150986 Renewal 03/21/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)The current physical examination dated 7/05/18 for Individual #1 did not document information pertinent to diagnosis in case of emergency; the area on the physical examination was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical for Individual #1 was returned to the family who had the provider complete the "Medical Information Pertinent to Diagnosis and Treatment in Case of an Emergency" section. For any emergency, staff should immediately call 911. (Attachment #1). In order to prevent blank spaces on physicals in the future, program specialists will use a physical checklist to ensure all sections are filled in (Attachment #2). 04/16/2019 Implemented
2380.111(c)(11)The current physical examination dated 7/05/18 for Individual #1 did not document special diet instructions; the area on the physical examination was left blank.The physical examination shall include: Special instructions for an individual's diet.The physical for Individual #1 was returned to the family who had the provider complete the "Special Instructions for Individual's Diet" section. There were no special instructions noted. (Attachment #1). In order to prevent blank spaces on physicals in the future, program specialists will use a physical checklist to ensure all sections are filled in (Attachment #2). 04/16/2019 Implemented
SIN-00111070 Renewal 04/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(9)This section was blank on Individual #1's physical exam dated 9/7/16.The physical examination shall include: Allergies or contraindicated medication.Physical was returned to Individual #1's physician to have blank sections completed. (Attachment #4) A comprehensive physical exam checklist for program specialists to check exams they receive for thoroughness was also developed. (Attachment #5) 05/10/2017 Implemented
2380.111(c)(10)This section was blank on Individual #1's physical exam dated 9/7/16.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Physical was returned to Individual #1's physician to have blank sections completed. (Attachment #4) A comprehensive physical exam checklist for program specialists to check exams they receive for thoroughness was also developed. (Attachment #5) 05/10/2017 Implemented
2380.113(c)(3)This section was not filled on Staff #1's physical exam dated 3/21/2017.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.Avenues' Human Resource Manager contacted Occupational Medicine on 4/19/17 and had them complete the free from communicable disease statement that was missed during Staff #1's original physical on 3/21/17. A corrected evaluation was returned the same day. (Attachment #3) 04/19/2017 Implemented
2380.128(d)Staff #2 had her Annual Medication Practicum on 3/2/2016. She didn't have it again until 3/27/2017, which exceeds the annual requirement.A staff person who administers prescription medications or insulin injections to individuals shall complete the Medications Administration Course Practicum annually.A tracking sheet was developed to help insure that the staff will complete annual medication practicums within the required one year time frame. (Attachment #2) 05/10/2017 Implemented
2380.186(b)Individual #1 didn't sign his ISP Reviews on 3/29/17, 12/21/16, and 9/30/16; Individual #2 didn't sign her ISP Review on 10/17/16; and Individual #3 didn't sign his ISP Reviews on 4/11/17, 1/6/17, 10/6/16, and 7/6/16.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.If individuals refuse to attend the formal meeting, program specialist will meet with the individual, review the ISP, and have them sign the signature sheet within the required time frame. If an individual refuses to sign, that will be documented also. Meeting signature sheet was revised to indicate that the individual's signature is required. (Attachment #1) 05/10/2017 Implemented
SIN-00101904 Unannounced Monitoring 10/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.17(c)(1)Staff interviews indicate that Avenues failed to report an allegation of neglect and abuse of Individual #1 which was reported to Avenues Site Supervisor during the summer of 2016.The facility shall orally notify, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs:  The county mental health and mental retardation program of the county in which the facility is located if the individual involved in the unusual incident has mental illness or mental retardation.A formal investigation regarding this incident is being conducted by Advocacy Alliance, Service Access and Management (SAM), and Adult Protective Services (APS). Program Manager and Assistant Executive Director met with Site Supervisor on 10/24/16, to develop a plan to address this situation. Site Supervisor, Program Specialist and all Direct Care Staff will be retrained on the topics of Recognizing and Reporting Abuse, Sensitivity, Professional Boundaries, and Confidentiality based on recommendations from the investigations. Program Manager and Assistant Executive Director will also meet individually with all Direct Care Staff to reiterate Avenues policies on abuse and their role as mandated reporters, Adult Protective Services procedures, and the chain on command for reporting if staff find it necessary to follow up on an incident they previously reported. Efforts will be made to mentor and empower staff through training. Plans are being developed to restructure the staffing and programming which include environmental adjustments to the open floor plan and a regular rotation of staff to ensure a positive, safe, supportive environment for all program participants. Program Manager and Assistant Executive Director will do spot visits monthly for the next 6 months. 11/30/2016 Implemented
2380.82Two chairs were found obstructing the front door located in the large program area.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Chairs were immediately moved upon notification by the licensing inspector. All staff were reminded by site supervisor the day the violation occurred (10/4/16) that doorways, passageways, and exits must always be unobstructed. Program participants who enjoy looking out of the windows will be redirected away from the glass program door to other windows within the program room. Program Manager and Assistant Executive Director will do spot visits monthly for the next 6 months. 10/27/2016 Implemented
Article X.1007An administrator or employee who has reasonable cause to suspect that a recipient between the ages of 18-59 with a disability is a victim of abuse, neglect, exploitation or abandonment shall immediately make a report in accordance with Adult Protective Services (APS) Law (Act 70). Staff interviews indicate that Avenues failed to report an alligation of neglect and abuse of Individual #1 which was reported to Avenues Site Supervisor during the summer of 2016. When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.A formal investigation regarding this incident is being conducted by Advocacy Alliance, Service Access and Management (SAM), and Adult Protective Services (APS). Program Manager and Assistant Executive Director met with Site Supervisor on 10/24/16, to develop a plan to address this situation. Site Supervisor, Program Specialist and all Direct Care Staff will be retrained on the topics of Recognizing and Reporting Abuse, Sensitivity, Professional Boundaries, and Confidentiality based on recommendations from the investigations. Program Manager and Assistant Executive Director will also meet individually with all Direct Care Staff to reiterate Avenues policies on abuse and their role as mandated reporters, Adult Protective Services procedures, and the chain on command for reporting if staff find it necessary to follow up on an incident they previously reported. Efforts will be made to mentor and empower staff through training. Plans are being developed to restructure the staffing and programming which include environmental adjustments to the open floor plan and a regular rotation of staff to ensure a positive, safe, supportive environment for all program participants. Program Manager and Assistant Executive Director will do spot visits monthly for the next 6 months. 11/30/2016 Implemented
SIN-00089400 Renewal 03/17/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)There is an individual attending the program who is deaf and blind. The facility does not have a fire alarm system adapted to the needs of this individual. If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.A quote was received from Dynamark to install sirens/strobes in areas in question (office, kitchen, & changing room) and will be installed by Dynamark as soon as the are able. Individual in question (Individual 3) has become ill and was hospitalized since inspection took place on 3/17/16. It is unsure if or when he will return to program. If he does return, a team meeting will be held and a personal body device will be purchased prior to his return date for him to wear during program hours. However, regardless of personal body alarm, individual does need total staff assistance when evacuating in an emergency. 05/31/2016 Implemented
2380.111(a)Individual 4s last physical was completed on 3/12/2015, included several areas of the form that had information entered by the program specialist after the doctor completed the form leaving blanks. These areas include the following: physical limitations, Chest x-ray, specialist referral required, uses hearing aids/corrective lenses, and cardiovascular. The program specialist admitted to entering data into these areas after being told by program director that physicals could not have blanks. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual 4's new physical was completed on 3/9/16 and filled in in its entirety by the physician. (Attachments 3A & 3B). A comprehensive physical checklist was developed to ensure that all physicals that are received are completely filled out (Attachments 3C & 3D). At site supervisor meeting on 3/21/16, clarification was given by program director that all physicals must be completed entirely by the physician before they are accepted by the day program and filed in individual files. 03/21/2016 Implemented
2380.111(c)(8)Individual 2s physical dated 6/30/2014 does not list her physical limitations. Individual 2 requires total assistance from staff for all mobility needs and adult daily living skills.The physical examination shall include: Physical limitations of the individual.An addendum to Individual 2's physical indicating her mobility limitations was received from her physician on 4/20/16. (Attachment 4). A comprehensive physical checklist was developed to ensure that all physicals that are received are completely and accurately filled out with no blank spaces. (Attachments 3C & 3D). 04/20/2016 Implemented
2380.111(c)(11)Individual 2s physical dated 6/30/2015 stated "no" under special instructions for individual diet. However, individual 2s quarterly report dated 2/1/2016 states, individual 2 "eats a chopped diet (soft foods chopped into ½ inch pieces)." Also, in individual 2s annual assessment dated 12/16/2015, it is noted that she requires a chopped consistency diet. The physical examination shall include: Special instructions for an individual's diet.An addendum to Individual 2's physical indicating her specialized diet was received from her physician on 4/20/16. (Attachment 4). A comprehensive physical checklist was developed to ensure that all physicals that are received are completely and accurately filled out with no blank spaces. (Attachments 3C & 3D). 04/20/2016 Implemented
2380.171(a)Individual 1s record does not contain emergency information. Program Specialist stated they are unsure of whom the emergency contact at the residential provider. Emergency information for individuals shall be easily accessible at the facility.Individual 1's file was updated to reflect current emergency contact information. Because house supervisors change frequently or group homes sometimes do not have supervisors during interim periods, Residential Program Specialists will be listed at emergency contacts. (Attachment 2B) 04/20/2016 Implemented
2380.173(1)(ii)Individual 1s record is incorrect for hair color. The record states Individual 1 had light brown hair when actually Individual 1 is bald on the top of his head and has gray hair in the back. Individual 1 has very little gray hair on the sides of his head. Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Individual 1's personal information was updated to reflect current information. Personal information will be reviewed yearly with the team at the ISP review and updated as needed. (Attachment 2A) 04/20/2016 Implemented
2380.181(e)(13)(i)Individual 3s 2015 annual assessment does not include his progress in health over the past year. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.An addendum to Individual 3's assessment was completed and attached to the original. All future assessments will address relevant health and medical issues. The addendum will be emailed to the licensing representative. (Attachment 1) 04/20/2016 Implemented
2380.188(d)Individual 1s annual assessments from 2014 and 2015 include an objective that Individual 1 will continue to wipe his face after each meal. Individual 1 is reported as having little to no progress with this outcome from 2014 to 2015. Individual 4 continues to have the same outcomes from 7/2014, 2015, and 2016. Individual 4, who is deaf, continues to complete the same 2 goals: wipe off the table and pick up the trash and place in the trash bin after lunch/break; and will use his IPAD at the day program.The facility shall provide services that are age and functionally appropriate to the individual.Individual 1's next quarterly meeting is scheduled for 6/9/16 at which time his goals will be changed/updated. Individual 4's quarterly meeting was held on 4/8/16 and one goal was changed to an arts and crafts goal to improve coordination and fine motor skills. The team wanted to continue the goal of working on the iPad, but it will be updated to indicate specific activities on the device. Training will take place for program specialists on 4/25/16 to address changing goals or aspects of each goal if no progress is noted. 06/09/2016 Implemented
SIN-00056608 Renewal 12/19/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(a)Staff #1 has a hire date of 7/2013. There is no criminal history check.(a)  An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.A criminal history check was completed prior to hire date in July 2013, however, was not in staff's file. Another criminal record check was completed on 12/19/13 and came back with no criminal record (criminal record check will be mailed to inspector). In addition, a personnel file checklist was created by Human Resources Manager to verify all necessary paperwork is in each staff file (a copy of checklist will also be sent to inspector). -Fully Implemented CH 1/15/14 01/02/2014 Implemented
2380.111(a)Individual #1 had a physical examination completed on 1/13/12 and did not have another physical examination until 5/8/13.(a)  Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Physical letter reminders are sent by program specialists at least a month prior to due date. If a physical is not received by the due date, attempts will be made via phone, email, and mail (and documentation of each attempt kept in individual's file) to get a copy of the physical before the 15 day grace period expires. A copy of the physical tracking form will also be mailed to inspector. - Partially Implemented, Adequate Progress CH 1/15/14 01/09/2014 Implemented
2380.173(9)Individual #1 and Individual #2 have Individual Support Plans that require 1:1 supervision. The assessments for Individual #1and Individual #2 do not include 1:1 supervision. (9)  Content discrepancies in the ISP, the annual update or revision under §  2380.186.Assessments for individuals were completed before their 1:1 supervision began and were accurate at the time of assessment. Assessments were not updated to reflect changes in individual needs (i.e., supervision) when changes occurred. An assessment addendum form was developed to attach to assessments should individual needs change after an assessment is completed. (Form will be mailed to inspector.)The assessments have been updated to reflect the changes in the ISP. - Fully Implemented CH 1/15/14 01/09/2014 Implemented
2380.181(f)Individual #1 had an ISP meeting on 4/26/13. The assessment was sent to the SC on 4/5/13. Individual #2 had an ISP meeting on 3/13/13. The assessment was sent to the SC on 2/27/13. (f)  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).While the assessments were completed 30 days prior to the meeting date, they were not mailed and received by the SC at least 30 days prior to the date of the meeting. Program Specialist will ensure that assessments are received by team members at least 30 days prior to the date of the meeting. A tracking sheet for assessment mailing dates was developed and will be mailed to inspector. -Partially Implemented, Adequate Progress CH 1/15/14 01/09/2014 Implemented
SIN-00222286 Renewal 05/16/2023 Compliant - Finalized
SIN-00130515 Renewal 03/23/2018 Compliant - Finalized
SIN-00072543 Renewal 02/04/2015 Compliant - Finalized
SIN-00043388 Renewal 12/14/2012 Compliant - Finalized