Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235983 Renewal 11/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Staff #1had a biannual physical conducted on 1/6/21 then not again until 9/13/23 exceeding the regulatory 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.To correct this area of non-compliance, Avenues' biennial physical examinations will be scheduled for existing employees two weeks prior to the due date to ensure that physicals are completed and returned to Human Resources representative within the required time frame. Human Resources representative will be responsible for implementation and continued compliance of the plan. This issue was discovered before the actual licensing date (on 11/14/23) and testing sites were contacted by Human Resources so they are aware that physicals should be scheduled two weeks prior to due date on 11/16/23. Avenues Policy and Procedure for staff physicals was updated on 12/11/23. (Attachment #1) 12/11/2023 Implemented
2380.21(u)Individual #1 had their rights reviewed on 3/23/22. The next documented review of their individual rights occurred on 11/14/23. This extends beyond the required annual time frame.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Required yearly paperwork for all program participants will be completed at the same time annually. Individual Rights review, as well as all necessary authorizations, releases, and other required annual paperwork will be completed on the same date between mid-July and no later than August 1 each year so no more than one year elapses between reviews. 01/02/2024 Implemented
SIN-00205382 Renewal 11/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Tuberculin skin testing with negative results every 2 years. Individual #1 had a Tuberculin skin testing with negative results on 9/23/20 and their next one occurred on 10/25/22. 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.Letters listing due dates and requirements for program participant's physicals are sent to their homes prior to the physical due date yearly (Attachment #1). As soon as it was discovered that Individual #1's TB test was not completed with his physical, an additional letter was sent home (Attachment #2) informing the family of the requirement. 12/09/2022 Implemented
SIN-00194652 Renewal 11/03/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's physical exam dated 6/15/2021 did not contain all regulated items. The missing areas include: Vision/hearing; health maintenance needs/need for bloodwork; limitations; allergies; and information pertinent to diagnosis in case of emergency.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.A copy of Avenues physical form was FAXED to Individual #1's primary care physician and completed in its entirety, including vision/hearing; health maintenance needs; need for bloodwork; limitations; allergies; and information pertinent to diagnosis in case of emergency. (Attachment #1). 12/10/2021 Implemented
2380.21(u)Individual #1 was admitted on 9/21/2021. He wasn't informed of his rights until 10/26/2021.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Program Specialist/Site Supervisor will ensure all releases and necessary paperwork are completed and signed by the individual and/or legal guardian no later than the first day of service. 12/10/2021 Implemented
SIN-00160772 Renewal 08/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #1 had an assessment on 1/3/2018. He didn't have another assessment completed until 1/24/2019, which exceeds the annual requirement.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Several training sheets and checklists were created by the program to address this issue and prevent any future assessments or paperwork from being out of compliance. A quick reference training sheet containing paperwork due dates and protocols (Attachments #2A & #2B), a file audit checklist with paperwork due dates (Attachments #3A & #3B), and a caseload tracking sheet (Attachment #4) were all developed and will be used for all individuals. 08/27/2019 Implemented
2380.125(f)Individual #2 is prescribed Sertraline (25mg QD). She does not have a SEEN Protocol in her record.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.A SEEN Plan was developed for Individual #2 on 8/13/19 to address her diagnosis of "behavioral disorder" (Attachment #1), however, as per her ISP and physical, she is not prescribed Sertraline or any psychotropic medications. The only medications listed are Vitamin D3, Flintstones Multivitamin, Naproxen for pain, and Ventolin inhaler and Symbicort for asthma. 08/13/2019 Implemented
SIN-00138209 Renewal 07/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(c)(2)Staff #1 has a bachelor's degree, but does not have the required two years experience working directly with persons with disabilities.A program specialist shall have one of the following groups of qualifications:(2)  A bachelor¿s degree from an accredited college or university and 2 years of work experience working directly with persons with disabilities.Lead Program Specialist (LTS) will serve as Program Specialist for the Adult Training Facility until Staff #1 reaches her required 2 years of work experience working directly with persons with disabilities (which will be August 28, 2019). Program Specialist LTS has a BS from Mansfield (Attachment #3) and has worked at Avenues in day programs directly with persons with disabilities since October 2004. She also does not currently have a caseload, so she will not exceed the maximum 30 individuals. 07/18/2018 Implemented
2380.111(a)Individual #1 had a late annual physical. He had one 09-20-16, then not again until 10-23-17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Specialist will use newly created physical tracking sheets (Attachments 1 & 2) to ensure that physicals are completed and received in the required time frame and filled out completely. If physicals are unable to be completed in compliance with regulations, the individual will not be permitted to attend program until the physical is completed and received by the Program Specialist. 08/01/2018 Implemented
SIN-00119837 Renewal 09/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)This section was not filled in on Individual #1's physical exam dated 5/31/2017. The physical examination shall include: Vision and hearing screening, as recommended by the physician.The physical was returned to individual #1's family to have this section completed by the PCP. (Attachment #1). An annual physical exam checklist was developed and will be used by Program Specialist to ensure all future physicals that are received have all sections completed. (Attachment #2). 10/18/2017 Implemented
2380.111(c)(10)This section was not filled in on Individual #1's physical exam dated 5/31/2017. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical was returned to individual #1's family to have this section completed by the PCP. (Attachment #1). An annual physical exam checklist was developed and will be used by Program Specialist to ensure all future physicals that are received have all sections completed. (Attachment #2). 10/18/2017 Implemented
SIN-00097245 Renewal 08/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Two individuals at the program do not have Tuberculin skin testing completed as regulated. Individual 1's physical dated 5/3/2016 is blank in the area of TB, and no other TB tests were on file. Individual 3's physical dated 9/18/2015 has a computerized attachment stating, "PPD 9/2/2014" which does not indicate the results of the TB test. 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 1 had a TB test given on 6/15/15 and read with a negative result on 6/17/15. (See Hazleton Individual 1 Attachment A.) The physician did not write the dates on her 2016 physical. Individual 3 had a TB test administered on 9/2/14 and read with normal results on 9/4/14. (See Hazleton Individual 3 Attachment A.) A comprehensive physical examination checklist was developed to prevent any issues in the future. (See Hazleton Physical Checklist Attachment.) 10/05/2016 Implemented
2380.111(c)(7)Individual 3s physical dated 9/18/2015 is blank for assessment of the individual's health maintenance needs, med regimen, blood work. 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.A comprehensive physical examination checklist was developed to prevent any issues in the future. (See Hazleton Physical Checklist Attachment.) Also, Individual 3 had a new physical completed on 9/20/16. (See Hazleton Individual 3 Attachment B.) 10/05/2016 Implemented
2380.111(c)(10)Individual 3's physical dated 9/18/2015 was left blank for the question of medical information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A comprehensive physical examination checklist was developed to prevent any issues in the future. (See Hazleton Physical Checklist Attachment.) Also, Individual 3 had a new physical completed on 9/20/16. (See Hazleton Individual 3 Attachment B.) 10/05/2016 Implemented
2380.113(c)(3)Direct care worker/staff 1's physical dated 8/10/2016 does not indicate if she is free of communicable diseases. The communicable disease section is absent from the physical form on file. 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.The free from communicable disease statement was completed at staff 1's physical on 8/1016, however, Avenues did not receive the form from the hospital. The necessary paperwork was faxed to Avenues the day of licensing, 8/18/16, and was added to staff 1's personnel file. Human resource manager contacted the hospital to address this issue and prevent any future occurrences. (See Hazleton Staff 1 Attachment A.) 08/18/2016 Implemented
2380.186(c)(2)All areas of the ISP are not being included in the ISP review. Individuals 2's and Individual 3's ISP reviews do not include a review of the safety areas of poisonous abilities, ability with heat sources, water regulation, swimming abilities, self-medication, and evacuation in the case of a fire. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.A new ISP review template including all of the required safety information was developed and will be used going forward. While this information was included on a special considerations page with the ISP review, specific safety areas were not addressed individually. (See Hazleton ISP Review Attachment.) 10/05/2016 Implemented
SIN-00081999 Initial review 07/17/2015 Compliant - Finalized