Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00177517 Renewal 11/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)There is a ceiling tile that has two brown circled water stains on it. This ceiling tile is located in the middle of the program area, on the left side of the wall. Also, on the same side of the program area, past the kitchen area along the wall, there are three areas the floor has had water damage. This was noticed after cabinets were removed when rearranging furniture for COVID standards. The rectangle areas are traced with a brown stain.Floors, walls, ceilings and other surfaces shall be in good repair.The Director and the Program Specialist (PS) are responsible to ensure the floors, wall, ceilings and other surfaces in good repair per regulation 2380.58(a) Surfaces. Staff was trained in the requirements of regulation 2380.58(a). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) The Program Specialist is responsible to report when floors, walls, ceilings and other surfaces are not in good repair to the Director. The Director is responsible to ensure that the necessary repairs are made so that all surfaces are in good repair. Water leak was repaired by Mid-State Mechanical Contractors. (Attachment # 3 Invoice 01/19/2021) Floors were stripped and waxed on 01/19/2020 by Whites Cleaning Service , Inc. (Attachment # 4 Invoice) 01/19/2021 Implemented
2380.70(b)No blanket in first aid area.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.Program Specialists are responsible to ensure that all needed items are kept in the first aid kit. Additionally, the Program Specialist needs to check the first aid kit following each monthly fire drill to ensure all required items are in the kit and to check for any expired items. Program Specialists were trained on regulation 2380.70 and their responsibilities. (Attachment # 5 -Training sheet, Attachment # 6 Memo) A blanket was placed in the first aid area. (Attachment # 7 Photo) 12/30/2020 Implemented
2380.70(d)No thermometer and antiseptic in the first aid kit.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.Program Specialists are responsible to ensure that all needed items are kept in the first aid kit. Additionally, the Program Specialist needs to check the first aid kit following each monthly fire drill to ensure all required items are in the kit and to check for any expired items. Program Specialists were trained on regulation 2380.70 and their responsibilities. (Attachment # 5 -Training sheet, Attachment # 6 Memo) A thermometer and antiseptic wipes have been placed in the first aid kit. (Attachment # 8 Photo) 12/30/2020 Implemented
2380.181(e)(3)(ii)ISP 10/20/2020 states individual #1 will rub his ears as a sign he is upset. This was not in his current assessment 7/13/2020.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication.It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each clients Assessment, per regulation 2380.181 (e)(3)(ii) - Communication. The Program Specialist was trained in the requirements of regulation 2380.181, specifically (e)(3)(ii). (Attachment # 9-Training sheet & Attachment # 10 - Memo) An Assessment Addendum was completed on 01/08/2021 for Individual #1, revising the 07/13/2020 Assessment clarifying the individuals current level of performance and progress in the following areas: Communication. (Attachment # 11 Assessment Addendum) The assessment addendum was sent to the Supports Coordinator on 01/13/2021. (Attachment #12 Email) Program Specialist is in the process of reviewing their caseload to ensure compliance. All records will be in compliance with this regulation by 02/26/2021. 02/26/2021 Implemented
2380.181(e)(9)It is reported in individual #1's current ISP 10/20/2020 that he should not eat corn. This is not in his current assessment 7/13/2020. Also, it is reported in his current ISP that individual should ever vomit, he is to be taken to the emergency department immediately. This is not in his current assessment 7/13/2020.The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each clients Assessment, per regulation 2380.181 (e)(9) Documentation of the individuals disability, including functional and medical limitations. The Program Specialist was trained in the requirements of regulation 2380.181, specifically (e)(9). (Attachment # 9-Training sheet & Attachment # 10 - Memo) An Assessment Addendum was completed on 01/08/2021 for Individual #1, revising the 07/13/2020 Assessment documenting the individuals disability, including functional and medical limitations. (Attachment # 11 Assessment Addendum) The assessment addendum was sent to the Supports Coordinator on 01/13/2021. (Attachment #12 Email) Program Specialist is in the process of reviewing their caseload to ensure compliance. All records will be in compliance with this regulation by 02/26/2021. 02/26/2021 Implemented
SIN-00164946 Renewal 12/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Two spray bottles of Blue All Purpose Cleaner were unlocked under the kitchen sink.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.It is the responsibility of the Program Specialists and Direct Service Workers to ensure that poisonous materials are kept locked or made inaccessible to individuals, when not in use per regulation 2380.53(a). The Program Specialists and Direct Service Workers were trained in the requirements of regulation 2380.53(a). (Attachment # 9 -Training sheet & Attachment # 10 - Memo) On 12/10/2019, upon discovery during licensing, the All Purpose Cleaner was moved from under the sink and made inaccessible in the locked supply closet. 12/11/2019 Implemented
2380.70(d)Triple Antibiotic Lotion Original Ointment expired August 2019 was in the First Aid Kit.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.Program Specialists are responsible to ensure that all needed items are kept in the first aid kit. Additionally, the Program Specialist needs to check the first aid kit following each monthly fire drill to ensure all required items are in the kit and to check for any expired items. Program Specialists were trained on regulation 2380.70 and their responsibilities. (Attachment # 7 -Training sheet, Attachment # 8 Memo) The expired Triple Antibiotic Lotion Original Ointment was removed from the First Aid Kit at the time of licensing. Antiseptic wipes were placed in the First Aid kit. 12/11/2019 Implemented
2380.111(c)(5)Individual #2's DOA was 4/15/19 his Tuberculin Chest X-ray was not completed until 7/9/19.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.Program Specialists are responsible to ensure that physicals contain all required information per regulation 2380.111, specifically 111(c)(5). The Program Specialists were trained in the regulation and their responsibilities. (Attachment # 4 -Training sheet & Attachment # 5 - Memo) Upon receipt of the physical examinations, Program Specialists are responsible to ensure all contents are included per regulation 111(c). Individual #2 did have an inital Chest X-ray, on July 6, 2015 - prior to admission into the program on 04/15/2019. The chest x-ray paper from Geisinger Medical Center was actually in the file however, it wasn¿t located until after the on-site licensing. (Attachment # 6 ¿ Chest X-ray results) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 01/31/2020. 01/31/2020 Implemented
2380.186Individual #1's current ISP dated 11/25/19 states he has an updated Social Dictionary with Networks For Communication. It further states he would like to keep adding to this dictionary so he can communicate as fully as possible with those around him. The current Social Dictionary at the Suncom program is dated 2008 and individual #1 is not using it nor has ever used it according to the Suncom team.The facility shall implement the individual plan, including revisions.Program Specialists are responsible to review each individuals ISP to ensure it is being implemented as written per regulation 186. The Program Specialist was trained in the requirements of regulation 2380.186. (Attachment # 1-Training sheet & Attachment # 2 - Memo) An email was sent to Individual #1s Supports Coordinator clarifying the status of the Social Dictionary. (Attachment # 3 E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 01/31/2020. 01/31/2020 Implemented
SIN-00146134 Renewal 12/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisons locked- The following poisons where found unlocked during the site inspection when all poisons are to be locked- Vics vapor rub and 2 cans of air freshener -- all marked to contact poison control center. These were in an unlocked cabinet outside the woman's restroom.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. All staff is responsible to meet the requirements of regulation 53a. Staff was trained on the regulation and their responsibility to ensure compliance. (Attachment #16 ¿ Training Sheet and Attachment #17 ¿ Memo) Upon discovery during on-site licensing visit 12/17/2018, the poisons were locked. They continue to be secured in a locked cabinet. 01/18/2019 Implemented
2380.113(a)Physical exam- Staff person #1 annual physical was completed late- 8/27/15- 9/21/17A 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.Per Regulation 113a, ¿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.¿ The Director is responsible to meet the requirements of regulation 113a. The Director was trained on the regulation and their responsibility to ensure compliance. (Attachment #13 ¿ Training Sheet and Attachment #14 ¿ Memo) A staff¿s physical paperwork indicates compliance with this regulation. (Attachment #15 ¿ Physicals) 01/18/2019 Implemented
2380.113(c)(2)Physical exam- TB test- Staff person #1's TB test was completed late-8/27/15- 9/21/17The 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.Per Regulation 113c, ¿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.¿ The Director is responsible to meet the requirements of regulation 113c. The Director was trained on the regulation and their responsibility to ensure compliance. (Attachment #13 ¿ Training Sheet and Attachment #14 ¿ Memo) A staff¿s physical paperwork indicates compliance with this regulation. (Attachment #15 ¿ Physicals) 01/18/2019 Implemented
2380.173(9)Individual #1 ISP and Assessment and Seizure Protocol does not include that the PRN medication Diazepam 2mg is also needed 1 tab by mouth every 8 hours as needed for spasms- per MARs for seizures.Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Per Regulation, 173(9), ¿Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186.¿ The Program Specialist is responsible to meet the requirements of regulation 173(9). The Program Specialist was trained on the regulation and their responsibility to ensure compliance. (Attachment #7 ¿ Training Sheet and Attachment #8 ¿ Memo) The Seizure Protocol was updated on 01/18/2019 to include the PRN medication Diazepam 2mg is also needed 1 tab by mouth every 8 hours as needed for spasms- per MARs for seizures. (Attachment #9 ¿ Seizure Protocol) Staff was trained on the updated Seizure Protocol. (Attachment #10 ¿ Training Sheet) An email was sent to the Supports Coordinator on 01/18/2019 to add Individual #1¿s seizure protocol to the ISP. (Attachment #11 ¿ Email) An Assessment Addendum was completed to include the seizure protocol for PRN Diazepam. (Attachment #12 ¿ Assessment Addendum) 01/18/2019 Implemented
2380.186(d)ISP review sent to all team members- Individual #2 'sFLP did not receive copies of the ISP reviews 10/17/18, 7/17/18, 4/17/18 & 1/17/18.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.Per Regulation, 186d, ¿The Program Specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.¿ The Program Specialist is responsible to meet the requirements of regulation 186d. The Program Specialist was trained on the regulation and their responsibility to ensure compliance. (Attachment #1 ¿ Training Sheet and Attachment #2 ¿ Memo) The (10/17/18, 7/17/18, 4/17/18 & 1/17/18) ISP Reviews were mailed to Individual #2¿s FLP on 01/17/2019. (Attachment #3 ¿ Letter) The Program Specialist will review the entire caseload to ensure compliance with this regulation by 02/15/2019. 02/15/2019 Implemented
2380.186(e)Option to decline- Individual #2 's FLP was not given the option to decline the ISP reviews.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Per Regulation 186e, ¿The Program Specialist shall notify the plan team members of the option to decline the ISP review documentation.¿ The Program Specialist is responsible to meet the requirements of regulation 186e. The Program Specialist was trained on the regulation and their responsibility to ensure compliance. (Attachment #4 ¿ Training Sheet and Attachment #5 ¿ Memo) The Option to Decline form was mailed to Individual #2¿s FLP for their review and signature. (Attachment #3 ¿ Letter and Attachment #6 ¿ Option to Decline form) The Program Specialist will review the entire caseload to ensure compliance with this regulation by 02/15/2019. 02/15/2019 Implemented
SIN-00121467 Renewal 10/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)The first aide kit was unlocked and accessable to individuals in the program. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. The Program Specialist is responsible to ensure that poisonous materials are kept locked or made inaccessible to individuals, when not in use per regulation 2380.53(a) ¿ Poisons. The Program Specialists and Direct Service Workers were trained in the requirements of regulation 2380.53(a). (Attachment # 18-Training sheet & Attachment # 19- Memo) On 10/23/2017,upon discovery during licensing, the First Aid kit was locked up / made inaccessible to individuals. 12/22/2017 Implemented
2380.111(c)(5)Individual #2's tuberculin skin test was adminsitered on 3/15/15 and 11/30/12. 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.55 PA Code Chapter 2380.111(c)(5)- Individual Physical Examination ¿ ¿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. The Program Specialist is responsible to ensure that each physical examination includes 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. If skin testing is positive, only an initial chest x-ray is required. Repeated chest x-rays are not required unless symptoms of tuberculosis occur such as coughing, unexplained weight loss, or night sweats per regulation 2380.111(c)(5). The Program Specialists were trained in the requirements of regulation. (Attachment #11- Training sheet & Attachment #12- Memo) The Program Specialist is responsible to notify individuals, families and/or residential providers of the need for required Physical Examinations, Tuberculin Skin test and Tetanus injections by mailing a memo 2 months prior to the expiration dates. (Attachment #13 Physical Memo) The Program Specialist is responsible to follow the Physical Memo Documentation Protocol for timely appointments for Individual Annual Physical Examinations, Tuberculin Skin Testing and Tetanus Injections. Program Specialists were trained on the Physical Memo Documentation Protocol. (Attachment #14 ¿ Training Sheet & Attachment #15 Physical Memo Documentation Protocol, Attachment #16 Individual Physical Memo and Attachment #17 Individual Physical) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/22/2017. 12/22/2017 Implemented
2380.124(a)Individual #3 medication atrificial tears 1.4% was not logged correctly on the MAR for the past year. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. All Medication Administration staff was trained in the requirements of regulation 2380.124(a). (Attachment # 8 -Training sheet & Attachment # 9 - Memo) (Attachment #10 ¿ Current MAR) Medication Administration Staff are in the process of reviewing their MARs to ensure compliance. All records will be in compliance with this regulation by 12/22/2017. 12/22/2017 Implemented
2380.181(e)(3)(i)Individual #1's assessment did not include acquistion of functional skills. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Acquisition of functional skills.It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client's Assessment, specifically the individual's acquisition of functional skills, regulation 2380.181 (e)(3)(i). Assessment. The Program Specialist was trained in the requirements of regulation 2380.181, specifically (e)(3)(i), (e)(5) and (e)(7). (Attachment # 4 -Training sheet & Attachment # 5 - Memo) An Assessment Addendum was completed for Individual #1, revising the 05/01/2017 Assessment clarifying the individual¿s acquisition of functional skills. (Attachment # 6 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members. (Attachment #7 ¿ Email) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/22/2017. 12/22/2017 Implemented
2380.181(e)(5)Individual #1's assessment did not include the ability to self adminster medications. The assessment must include the following information: The individual¿s ability to self-administer medications.It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client's Assessment, specifically the individual's ability to self-administer medications, per regulation 2380.181 (e)(5). ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181, specifically (e)(3)(i), (e)(5) and (e)(7). (Attachment # 4 -Training sheet & Attachment # 5 - Memo) An Assessment Addendum was completed for Individual #1, revising the 05/01/2017 Assessment clarifying the individual¿s ability to self-administer medications. (Attachment # 6 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members. (Attachment #7 ¿ Email) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/22/2017. 12/22/2017 Implemented
2380.181(e)(7)Individual #1's assessment did not include the ability to sense and move away from heat sources. The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.It is the responsibility of the Program Specialist to ensure compliance with this regulation and ensure that the required information is documented in each client¿s Assessment, specifically the individual¿s knowledge of the dangers of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated, per regulation 2380.181 (e)(7). ¿ Assessment. The Program Specialist was trained in the requirements of regulation 2380.181, specifically (e)(3)(i), (e)(5) and (e)(7). (Attachment # 4 -Training sheet & Attachment # 5 - Memo) An Assessment Addendum was completed for Individual #1, revising the 05/01/2017 Assessment clarifying the individual¿s knowledge of the dangers of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. (Attachment # 6 ¿ Assessment Addendum) The assessment addendum was sent to the Supports Coordinator and plan team members. (Attachment #7 ¿ Email) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/22/2017. 12/22/2017 Implemented
2380.183(4)Individual #1's ISP does not include need for community supervision. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. The Program Specialist was trained in the requirements of regulation 2380.183, specifically (4). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) An e-mail was sent to the Supports Coordinator for Individual # 1 ¿ requesting that the ISP be updated to include the individual¿s Community Supervision needs. (Attachment # 3 ¿ E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/22/2017. 12/22/2017 Implemented
2380.183(5)Individual #1's ISP does not include a SEEN plan. He is precribed zoloft 25mg QD for depression. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. The Program Specialist was trained in the requirements of regulation 2380.183, specifically (5). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) An e-mail was sent to the Supports Coordinator for Individual # 1 ¿ requesting that the ISP be updated to include a protocol to address the social, emotional and environmental needs of the individual, since he is prescribed Zoloft to treat symptoms of a diagnosed psychiatric illness, depression. (Attachment # 3 ¿ E-mail) Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 12/22/2017. 12/22/2017 Implemented
SIN-00101099 Renewal 09/24/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(10)Individual #2's assessment dated 2/4/16 did not have a lifetime medical history. The assessment must include the following information: A lifetime medical history.The Program Specialist is responsible to ensure the lifetime medical history is attached to the assessment per regulation 2380.181 (e)(10) ¿ Assessment. The Program Specialists were trained in the requirements of regulation 2380.181(e) (10). (Attachment # 6 -Training sheet & Attachment # 7 - Memo) On 09/26/2016 the Lifetime medical history was attached to Individual #2's 02/04/2016 Assessment. (Attachment #8¿ Assessment) The Program Specialist is in the process of reviewing their caseload to ensure compliance. All records will be in compliance with this regulation by 10/28/2016. 10/28/2016 Implemented
2380.183(7)(i)Individual #1's ISP did not include assessment of the potential to advance in vocational programming. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.The Program Specialist is responsible to ensure the ISP including annual updates and revisions include all necessary requirements per regulation 2380.183 ¿ Contents of the ISP ¿specifically (7), assessment of the individual¿s potential to advance in: (i) Vocational programming and (iii) Competitive community-integrated employment. The Program Specialist was trained in the requirements of regulation 2380.183(7), specifically (i) and (iii). (Attachment # 3 -Training sheet & Attachment # 4 - Memo) On 09/29/2016 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #1¿s ISP to include an assessment of the individual¿s potential to advance in Vocational programming and Competitive community-integrated employment. (Attachment #5 ¿ Email) The Program Specialist is in the process of reviewing their caseload to ensure compliance. All records will be in compliance with this regulation by 09/29/2016. 09/29/2016 Implemented
2380.183(7)(iii)Individual #1's ISP did not include assessment of the potential to advance in competitive community integrated employment. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.The Program Specialist is responsible to ensure the ISP including annual updates and revisions include all necessary requirements per regulation 2380.183 ¿ Contents of the ISP ¿specifically (7), assessment of the individual¿s potential to advance in: (i) Vocational programming and (iii) Competitive community-integrated employment. The Program Specialist was trained in the requirements of regulation 2380.183(7), specifically (i) and (iii). (Attachment # 3 -Training sheet & Attachment # 4 - Memo) On 09/29/2016 the Program Specialist sent an e-mail to the Supports Coordinator addressing the need for individual #1¿s ISP to include an assessment of the individual¿s potential to advance in Vocational programming and Competitive community-integrated employment. (Attachment #5 ¿ Email) The Program Specialist is in the process of reviewing their caseload to ensure compliance. All records will be in compliance with this regulation by 09/29/2016. 09/29/2016 Implemented
2380.184(a)(1)(ii)Individual #1's ISP meeting did not inlcude a Program Specialist in attendance. The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision). A plan team must include as its members the following: A program specialist or family living specialist, as applicable, from each provider delivering a service to the individual.The Program Specialist is responsible to participate in the development of the Individual Support Plan, including the annual updates and revisions under 2380.186 (relating to ISP review and revision). Per 2380.184(a)(1) ¿ Plan Team Participation, ¿A plan team must include as its members the following: (i) ¿ The individual, (ii) ¿ A program specialist or family living specialist, as applicable, from each provider delivering service to the individual, (iii) ¿ A direct service worker who works with the individual from each provider delivering a service to the individual and(iv) ¿ Any other person the individual chooses to invite. It is the Program Specialist¿s responsibility to ensure that they or their designee participates in the development of the Individual Support Plan, including the annual updates and revisions. The Program Specialist was trained in the requirements of regulation 2380.184(a)(1), specifically (ii). (Attachment # 1 -Training sheet & Attachment # 2 - Memo) 10/10/2016 Implemented
SIN-00038852 Renewal 08/27/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(12)There are no recommendations for training, programming or services in the assessments for Individuals #1 & #2.(e)  The assessment must include the following information: (12)  Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The Program Specialist is responsible to ensure that the required information is documented in the assessment. The Program Specialist was retrained on the requirements of regulation 181(e)(12). Attachment A The Program Specialist completed an assessment which included recommendations for specific areas of training and service. Attachment B. 09/19/2012 Implemented
2380.181(e)(13)(i)There is no progress or growth discussed in areas (i) through (vi) of the assessments for Individuals #1 & #2.(e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level.The Program Specialist is responsible to ensure that the required information is documented in the assessment. The Program Specialist was retrained on the requirements of regulation 181(e)(13). Attachment A The Program Specialist completed an assessment which included the individual's progress over the last 365 calendar days and current skill level in the following areas; health, motor & communication skills, personal adjustment, socialization, recreation and community integration. Attachment B. 09/19/2012 Implemented
SIN-00237228 Renewal 01/11/2024 Compliant - Finalized
SIN-00218913 Renewal 02/01/2023 Compliant - Finalized
SIN-00197882 Renewal 01/05/2022 Compliant - Finalized
SIN-00084020 Renewal 08/28/2015 Compliant - Finalized