| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
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SIN-00236325
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Renewal
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01/05/2024
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.82 | The Rear Exit Door sticks on bottom of door. The door requires two hands to pull it closed. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | The Director is responsible for ensuring compliance with this regulation. The Director was trained in the requirements of regulation 2380.82. (Attachment # 1 -Training sheet & Attachment # 2 - Memo)
SUNCOMs Landlord sent a repairman to fix the issue on 01/11/2024. Adjustments were made to the strip (threshold) at the bottom of the door. The threshold was lowered. Adjustments were also made to one bracket (hinge). The hinge was tightened. The door now closes and opens smoothly. (Attachment #3 Photo- Threshold) (Attachment #4 Hinge) (Attachment #5 Closed door). |
01/11/2024
| Implemented |
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SIN-00217946
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Renewal
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01/24/2023
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.183(a)(3) | Individual #1's ISP meeting held on 8/11/2022 did not include a DSP. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | The Program Specialist is responsible to ensure that the Direct Service Worker participates in the development of the Individual Plan, including the annual updates and revisions.
The Program Specialist is responsible to coordinate the development of the Individual Plan, including the annual updates and revisions under 2380.182 (relating to Development, Annual Update and Revision of the Individual Plan). The Program Specialist was trained in the requirements of regulation 2380.183(a)(3). (Attachment # 1 -Training sheet & Attachment # 2 - Memo)
If the direct service worker is unable to attend the meeting in person due to staffing issues or other unforeseen circumstances, they will complete the Input for ISP Planning Meeting form so their information can be shared at the meeting by the Suncom Program Specialist. (Attachment #3 ¿ form)
Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 02/24/2023. |
02/24/2023
| Implemented |
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SIN-00180112
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Renewal
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12/03/2020
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.181(e)(5) | Individual # 2's Assessment reads "It is unknown the ability or skill set that he would have to know the five rights to medication management. In the even Individual # 2 were to need to take medication, the team would discuss steps to take to teach about his medication and how to administer his medication. Individual # 2's ability to self-medicate was not determined. | 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 clients Assessment, specifically the individuals 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)(5). (Attachment # 1-Training sheet & Attachment # 2 - Memo)
An Assessment Addendum was completed on 12/09/2020 for Individual #2, revising the 08/14/2020/updated 10/28/2020 Assessment clarifying the individuals ability to self-administer medications. (Attachment # 3 Assessment Addendum)
The assessment addendum was sent to the Supports Coordinator on 12/10/2020. (Attachment #4 Email)
Program Specialist is in the process of reviewing their caseload to ensure compliance. All records will be in compliance with this regulation by 01/31/2021. |
01/31/2021
| Implemented |
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SIN-00167406
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Renewal
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11/26/2019
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.57 | The rear egress by the bathroom hallway had an inoperable exterior light bulb above the outside steps. | Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. | The Direct Service Workers are responsible to report to the Program Specialist when rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes are not well light, when light bulbs need replaced or if lights are not in working order to assure the safety of program participants and staff. The Program Specialist is responsible to ensure that light bulbs are replaced and to report to the Director when lights are not in working order. The Director is responsible to ensure that the necessary repairs are made so that all surfaces are in good repair and free of hazards. If staff notice safety concerns or items in need of repair, they are to contact their program specialist or manager immediately.
The Program Specialist is responsible to replace light bulbs and report to the Director when lights are not in working order. The Director is responsible to ensure that the necessary repairs are made so that rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. If staff notice safety concerns or items in need of repair, they are to contact their program specialist or manager immediately.
The Direct Service Workers, Program Specialists and Director were trained on regulation 2380.57a and their responsibilities. (Attachment # 15 -Training sheet, Attachment # 16 Memo and Attachment # 17 - Photo) |
11/27/2019
| Implemented |
| 2380.58(a) | The walls in the pink room had multiple scuff marks on all four walls and two unfinished drywall patches on front of building wall which were not painted. The entire room needs repainted. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Director, Program Specialists and Direct Service Workers are responsible to ensure the floors, walls, ceilings and other surfaces are free of hazards per regulation 2380.58(a).
The Direct Service Workers are responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Program Specialist. The Program Specialist is responsible to report when floors, walls, ceilings and other surfaces are not free of hazards to the Director. The Director is responsible to ensure that the necessary repairs are made so that all surfaces are in good repair and free of hazards. If staff notice safety concerns or items in need of repair, they are to contact their program specialist or manager immediately.
The Direct Service Workers, Program Specialists and Director were trained on regulation 2380.58a and their responsibilities. (Attachment # 13 -Training sheet & Attachment # 14 Memo)
The pink room had multiple scuff marks on all four walls and two unfinished drywall patches on front of building wall which were not painted. The room will be re-painted by 01/31/2020. |
01/31/2020
| Implemented |
| 2380.89(c) | The fire drills which were held on 08/07/19, 05/06/19 and 04/25/19 do not include problems encountered. Space left blank on Fire drill forms. | 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 was operative. | Program Specialists are responsible to ensure the Monthly Fire Drill form is completed per regulation 2380.89c. When the Program Specialist completes the fire drill form, please ensure all items listed above, including problems encountered are filled in. If there were no problems encountered, then list None. There should not be any blanks on the form. If the Program Specialist is unsure how to complete the form, they were directed to contact their Manager for assistance.
Program Specialists were trained on regulation 2380.89c and their responsibilities. (Attachment # 10 -Training sheet, Attachment # 11 Memo & Attachment # 12 December Fire Drill form) |
12/19/2019
| Implemented |
| 2380.111(c)(10) | Individual #2's 12/13/18 physical exam does not include information pertinent to diagnosis in case of an emergency. The space was left blank on the physical. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialists are responsible to ensure that physicals contain all required information per regulation 2380.111, specifically 111(c)(10). The Program Specialists were trained in the regulation 2380.111c10 and their responsibilities. (Attachment # 7 -Training sheet & Attachment # 8 - Memo)
Upon receipt of the physical examinations, Program Specialists are responsible to ensure all contents are included per regulation 111(c). Please review your caseload and ensure that all physicals are in compliance with this regulation by 01/31/2020.
Individual #1s 12/13/2018 Physical Examination was revised to include medical information pertinent to diagnosis and treatment in case of an emergency. (Attachment # 9 Physical)
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 |
| 2380.181(a) | Individual #2 date of admission is 04/19/19. His initial assessment was not completed until 07/09/19 which is beyond the 60 day 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. | Program Specialists are responsible to ensure that assessments are completed in a timely manner per regulation 2380.181(a). The Program Specialists were trained in the regulation 2380.181a and their responsibilities. (Attachment # 5 -Training sheet & Attachment # 6 - Memo)
There has been no new admission to the program since licensing on 11/26/2019.
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 |
| 2380.181(e)(5) | Individual #1's assessment 1/4/2019 states he is able to self-medicate, but needs someone to fill his pill box weekly, as well as secure his prescriptions. His family assists with obtaining refills. Complete self-medication could be a foreseeable future goal for individual #1. Individual #1's ability to self-medicate is unclear. | 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 clients Assessment, specifically the individuals 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 # 1-Training sheet & Attachment # 2 - Memo)
An Assessment Addendum was completed for Individual #1, revising the 01/04/2019 Assessment clarifying the individuals ability to self-administer medications. (Attachment # 3 Assessment Addendum)
The assessment addendum was sent to the Supports Coordinator. (Attachment #4 Email)
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 |
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SIN-00146065
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Renewal
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12/19/2018
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.183(7)(i) | The 10/1/18 ISP for Individual #1 did not contain the potential to advance in vocational programming. This section was left blank. | 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. | Per Regulation, 183(7)(i), ¿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 meet the requirements of regulation 183(7)(i). The Program Specialist was trained on the regulation and their responsibility to ensure compliance. (Attachment #5 ¿ Training Sheet and Attachment #6¿ Memo)
An email was sent to the Supports Coordinator asking that Individual #1¿s potential to advance in Vocational programming be added to the ISP. (Attachment #7 ¿ Email)
The Program Specialist or designee will review the entire caseload to ensure compliance with this regulation by 02/28/2019. |
02/28/2019
| Implemented |
| 2380.183(7)(iii) | Competitive Community integrated employment- The ISP 10/1/18 for Individual #1 did not contain the potential to advance in competitive community integrated employment- this section only stated working on employment skills. | 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. | Per Regulation 183(7)(iii), 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 meet the requirements of regulation 183(7)(iii). The Program Specialist was trained on the regulation and their responsibility to ensure compliance. (Attachment #5¿ Training Sheet and Attachment #6 ¿ Memo)
An email was sent to the Supports Coordinator asking that Individual #1¿s potential to advance in Competitive community-integrated Employment be added to the ISP. (Attachment #7 ¿ Email)
The Program Specialist or designee will review the entire caseload to ensure compliance with this regulation by 02/28/2019. |
02/28/2019
| Implemented |
| 2380.186(e) | Option to decline- individual #1 parents where 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 #1 ¿ Training Sheet and Attachment #2 ¿ Memo)
The Option to Decline form was mailed to Individual #1¿s FLP for their review and signature. (Attachment #3 ¿ Letter and Attachment #4 ¿ Option to Decline form)
The Program Specialist or designee will review the entire caseload to ensure compliance with this regulation by 02/15/2019. |
02/15/2019
| Implemented |
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SIN-00121453
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Renewal
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10/11/2017
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.82 | There was a storage bin and a dumpster blocking the sliding glass door egress route from the exterior of the building. The sliding glass door was marked "not an exit" from the interior of the building and partially covered with a curtain. During the inspection, the curtain was open giving the appearance of an exit and individuals in the program have access to the door. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | 55 PA Code Chapter 2380.82 ¿Unobstructed Egress- Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.
The sliding glass door in the program area is not used as an entry way or as an exit in the event of a fire. The appearance of the sliding glass door has been modified to better reflect that it is not an exit. (Attachment # 15 ¿ Photo) |
10/27/2017
| Implemented |
| 2380.186(c)(1) | Individual #1 and Individual #2's Individual Support Plan (ISP) Reviews do not include progress toward the ISP outcomes of socialization and adaptive self help, respectively. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | 10/13/2017
55 PA Code Chapter 2380.186(c)(1) ¿ISP review and revision- The ISP review must include the following: (c)(1) A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months towards ISP outcomes supported by services provided by the facility licensed under this chapter.
The Program Specialists are responsible to ensure that the Individual Support Plan (ISP) Review includes a review of each section of the ISP, progress toward their outcome. The Program Specialists were trained in the requirements of regulation 2380.186(c)(1). (Attachment # 1-Training sheet & Attachment # 2- Memo)
Individual #1's Individual Support Plan (ISP) reviews dated 09/01/2017, 06/01/2017, 03/01/2017 and 12/01/2016 did not indicate progress toward his outcome. ISP Review Addendum notes were completed to include documentation of the individual's progress toward his outcome for the ISP Reviews for 09/01/2017, 06/01/2017, 03/01/2017 and 12/01/2016. (Attachment # 3 ¿ 09/01/2017 ISP Review Addendum, Attachment # 4 - 06/01/2017 ISP Review Addendum, Attachment # 5 - 03/01/2017 ISP Review Addendum and Attachment # 6 - 12/01/2016 ISP Review Addendum) Additionally, a Detailed Action Plan was developed to measure progress towards the outcome. (Attachment #7 ¿ Detailed Action Plan)
An e-mail was sent to the Supports Coordinator for Individual # 2 ¿ notifying them of the revisions. (Attachment # 8 ¿ E-mail)
Individual #2's ISP reviews dated 10/20/2017, 07/21/2017, 04/19/2017 and 01/19/2017 did not indicate progress toward his/her outcome. ISP Review Addendum notes were completed to include documentation of the individual¿s progress toward his outcome for the ISP Reviews for 10/20/2017, 07/21/2017, 04/19/2017 and 01/19/2017. (Attachment # 9 ¿ 10/20/2017 ISP Review Addendum, Attachment # 10 - 07/21/2017 ISP Review Addendum, Attachment # 11 - 04/19/2017 ISP Review Addendum and Attachment # 12 - 01/19/2017 ISP Review Addendum) Additiona |
11/30/2017
| Implemented |
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SIN-00102593
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Renewal
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10/19/2016
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.183(7)(iii) | Individual #1's ISP dated 1/13/16 did not indicate potential to advance in vocational programming towards competitive community 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: (iii) Competitive community-integrated employment.
The Program Specialist was trained in the requirements of regulation 2380.183(7), specifically (iii). (Attachment # 4-Training sheet & Attachment # 5 - Memo)
On 11/02/2016 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 Competitive community-integrated employment. (Attachment #6 ¿ 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 11//2016. |
11/30/2016
| Implemented |
| 2380.184(a)(1)(iii) | A direct support staff did not attend Individual #2's ISP meeting held on 1/5/16. | 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 direct service worker who works with the individual 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 the direct service worker 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 (iii). (Attachment # 1 -Training sheet & Attachment # 2 - Memo)
If the direct service worker is unable to attend the meeting in person due to staffing issues or other unforeseen circumstances, they will complete the Input for ISP Planning Meeting form so their information can be shared at the meeting by the Suncom Program Specialist. (Attachment #3 ¿ form) |
11/02/2016
| Implemented |
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SIN-00086187
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Renewal
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10/02/2015
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.173(9) | Individual #2's ISP states his only allergies as "grass/hay". Physical states "prednisome and statins". | 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 ensure that each record includes content discrepancies in the ISP, the annual update or revision under 2380.186. The Program Specialist was trained in the requirements of regulation 2380.173(9). (Attachment #1-Training sheet & Attachment# 2 - Memo)
Individual #2¿ The citation stated that the ISP and physical did not match. The ISP indicated that the allergies as ¿grass/hay¿. The physical states ¿prednisone and statins". The content discrepancy between the ISP and the Physical Examination was resolved on 11/10/2015. (Attachment #3- Email to SC and Attachment #4 ¿ ISP-Updated Allergies section)
The Program Specialist is in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2015.
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11/30/2015
| Implemented |
| 2380.181(e)(7) | Individual #1's assessment does not inlcude ability to 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. | The Program Specialist is responsible to ensure each assessment includes the individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degree F and are not insulated. The Program Specialist was trained in the requirements of regulation 2380.181(e)(7). (Attachment #5- Training sheet & Attachment #6- Memo)
Individual #1 - The assessment was updated on (10/26/2015) to include the individual¿s understanding of the danger of heat sources and her ability to sense and move away from heat sources quickly. (Attachment #7- Assessment)
The Program Specialist is in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2015.
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11/30/2015
| Implemented |
| 2380.184(b) | Individual #2's ISP review was conducted on 5/20/15 and only the Individual, PS and SC attended. | At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting. | The Program Specialist is responsible to ensure that at least three (3) plan team members, in addition to the individual, if the individual chooses to attend, shall be present for the ISP, annual update and ISP revision meetings. The Program Specialist was trained in the requirements of regulation 2380.184(b). (Attachment #8-Training sheet & Attachment #9- Memo)
Individual #2 - There has not been an ISP meeting, annual update or ISP revision meeting since licensing in October 2015, however the next meeting is scheduled in August 2016. Three team members in addition to the individual are scheduled to attend the meeting. If at least three team members and the individual are not in attendance then the meeting will be rescheduled to remain in compliant with this regulation.
The Program Specialist is in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/30/2015.
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11/30/2015
| Implemented |
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SIN-00070287
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Initial review
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11/14/2014
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.58(b) | Molding strip in program area is uneven and could cause a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | During the inspection a molding strip in program area was found to be uneven and could cause a tripping hazard. The Facilities Manager, Jonathan Sharpe, repaired the trip hazard, thus eliminating the safety hazard.
Current photo of door threshold indicating elimination of the safety hazards. (Attachment - photo -send to Amy Knaus on 12/02/2014)
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11/21/2014
| Implemented |
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SIN-00197877
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Renewal
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01/05/2022
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Compliant - Finalized
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SIN-00151505
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Renewal
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04/04/2019
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Compliant - Finalized
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