Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00188355 Renewal 05/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Individual #1, Individual #2 and Individual #3 have not been informed of their rights for 2020 and 2021.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Program specialists are now reviewing individual rights with all program participants as they attend program on their scheduled days. Review of individual rights was completed with Individual #1, Individual #2, and Individual #3 on 6/17/21. 06/17/2021 Implemented
SIN-00150985 Renewal 03/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.81A rear exit was completely blocked on the outside by wood, making egress impossible. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.As the rear exit was being inspected, staff immediately removed the wood outside of the exit so it would not be blocked in the event an exit at that location would need to be used. Following the exit interview, staff and participants were given a refresher verbal training by site supervisor, H.K. on the importance of safety in the workplace and being aware of your surroundings. 03/26/2019 Implemented
2390.82(a)There were not evacuation diagrams specifying directions for all exits for egress in the work area. NOTE: THIS WAS CORRECTED AT TIME OF INSPECTIONWritten emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas.Immediately following the exit interview on 3/26/19 involving the discussion of the directions and evacuation diagrams, the exits not showing the proper documentation where provided and updated according to the Code Chapter for 2390.82 All exits at this location currently have the proper responsibilities, transportation, shelter location and diagrams listed for emergency situations. 03/26/2019 Implemented
SIN-00130513 Renewal 03/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(13(ii)The annual assessment dated 7/10/17 for Individual #1 did not document progress over the last 365 days in the area of motor and communication. The annual assessment dated 5/16/17 for Individual #2 did not document progress over the last 365 days in the area of motor and communication.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 annual assessment has been restructured to include the adequate information explaining every individual's progress over the last 365 calendar days. The current level including motor and communication skills can be located in the Medical & Safety outline. 03/19/2018 Implemented
2390.153(5)Individual #1 is taking Lorazepam for anxiety and there was no protocol to address the social, emotional and environmental needs of the individual in the record.A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.A SEEP Plan was implemented immediately for this individual that was missed and moving forward all plans in the agency will be reviewed monthly at our Internal Review Committee meetings. This review will be set up to keep all individual files in compliance and up to date on the participant's protocol. 03/16/2018 Implemented
SIN-00071398 Renewal 02/03/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 was admitted into the Avenues Habilitation Horticulture Vocational Program on July 16, 2014 and did not receive the initial fire safety instruction until July 23, 2014.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.An updated Prevocational Admission Check List has been created. Included in the checklist is the Initial Fire Safety Training date. Also, a separate Initial Fire Safety Training Documentation Form has been created that lists the Admission Date and the Date of the Initial Fire Safety Training which both dates are to be exact. Included in this form is, the length of training, viewing the Fire Safety DVD, Discussion and Review, Reviewing all Exit routes in the building, and reviewing the designated meeting place. This form will also be attached to the Training Record. Maureen DeNapoli, Lead Program Specialist will be monitoring /auditing on a regular basis and Francine Trakes, Vocational Program Manager will also do spot audits. 02/20/2015 Implemented
SIN-00058359 Renewal 12/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The ceiling in the front Greenhouse area towards the front door is sagging and has a steady leak which has caused an approximately 3ft wide green puddle to form on the floor. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Due to the continuous snow and sub zero temperatures that we have been experiencing this winter season, our contracted roofers, Happy Construction, Gordonville, PA, have not been able to go up on our roof and make the acquired repairs. They will be making a repair to the seam of our greenhouse roof which has caused the leak and the sagging greenhouse curtain. Following these repairs, the greenhouse floor underneath the leak will be powerwashed and sanitized and free of visible hazards and in good repair. 01/30/2014 Implemented
2390.81A door marked as a fire exit to the side of the front Greenhouse area lead to a ramp that was covered in approximately 3 inches of snow. The door had to be forcibly pushed open as the snow created a blockage. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.As soon as this issue was discovered, the area/ramp marked exit was shoveled and made available for emergency status. Following this, an immediate plan was placed to assign staff to different areas throughout the greenhouse, having each staff monitor their designated areas of exit in inclimate weather. The staff is to make sure their exit areas are unobstructed and ready to be used in an emergency status. 12/19/2014 Implemented
SIN-00222284 Renewal 05/04/2023 Compliant - Finalized
SIN-00205368 Renewal 06/02/2022 Compliant - Finalized
SIN-00172161 Renewal 03/06/2020 Compliant - Finalized
SIN-00111072 Renewal 04/19/2017 Compliant - Finalized
SIN-00089401 Renewal 03/03/2016 Compliant - Finalized