Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224492 Renewal 05/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Direct Service Worker #2 was instructed in general fire safety and the use of fire extinguishers on 3/17/22 and then again on 5/9/23. Direct Service Worker #3 was instructed in general fire safety and the use of fire extinguishers on 3/17/22 and then again on 5/9/23.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.All new staff hired, and clients as appropriate, will be instructed on general fire safety and in the use of fire extinguishers. This training will be conducted by the Human Resources department and coordinated with the initial onboarding process. Annual fire training will be provided to all team members by the organization within 365 days of the previous training date. Staff members #2 and #3 who were in violation completed the training on 5/9/23 05/09/2023 Implemented
2390.49(c)(1)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #1 did not encompass community integration, client choice, and supporting clients to develop and maintain relationships. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #2 did not encompass person centered practices, community integration, client choice, and supporting clients to develop and maintain relationships. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass person centered practices, community integration, client choice, and supporting clients to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships.The organization will create a training presentation that encompasses all of the requirements as it pertains to person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships. The 6100 Regulation Training will cover all necessary information to ensure compliance with the application of person-centered practices, community integration, client choice and supporting clients to develop and maintain relationships. Staff member #1 completed the required trainings on 6/26/22 Staff member #2 completed the required trainings on 3/3/22, 5/11/22, 9/30/22, 12/5/22, 3/26/23 06/07/2023 Implemented
2390.49(c)(2)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #1 did not encompass prevention, detection, and reporting of abuse. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #2 did not encompass prevention, detection, and reporting of abuse. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass prevention, detection, and reporting of abuse.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The organization will create a training presentation that encompasses all of the requirements as it pertains to the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. && 10225.101 -10225.5102), the child protective services law (23 Pa C.S && 6301 - 6386), the Adult Protective Services Act (35 P.S. && 10210.101-10210.704) and applicable protective services regulations. The 6100 Regulation Training will cover all necessary information to ensure compliance with the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. && 10225.101 -10225.5102), the child protective services law (23 Pa C.S && 6301 - 6386), the Adult Protective Services Act (35 P.S. && 10210.101-10210.704) and applicable protective services regulations. Staff member #1 completed training on 6/7/23 06/07/2023 Implemented
2390.49(c)(3)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass Individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.The organization will create a training presentation that encompasses all of the requirements as it pertains to Client Rights. The 6100 Regulation Training will cover all necessary information to ensure compliance with Client Rights. Staff member #3 completed this training on 6/5/23. 06/05/2023 Implemented
2390.49(c)(4)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #3 did not encompass recognizing and reporting incidents. The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #4 did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The organization will create a training presentation that encompasses all of the requirements as it pertains to Recognizing and Reporting Incidents. The 6100 Regulation Training will cover all necessary information to ensure compliance with Recognizing and Reporting Incidents. Staff member #3 completed this training on 5/25/23 Staff member #4 completed this training on 12/7/22 06/07/2023 Implemented
2390.49(c)(5)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #4 did not encompass behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with a client.The organization will create a training presentation that encompasses all of the requirements as it pertains to Behavior Supports. The 6100 Regulation Training will cover all necessary information to ensure compliance with Behavior Supports. Staff member #4 completed this training on 4/13/23 06/07/2023 Implemented
2390.49(c)(6)The annual training from 7/1/21 to 6/30/22 for Direct Service Worker #4 did not encompass implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with a client.The team members who directly work with a client will be responsible to review the ISP of each individual that they work with during their job. The list of clients to be reviewed will be provided by the Program Specialist and the direct support professional and program specialist will work together to ensure that each plan is reviewed and accounted for during the training year. Staff member #4 completed this training on 6/5/23 06/05/2023 Implemented
SIN-00206883 Renewal 06/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Direct Service Worker #1, date of hire 8/16/2021, was instructed in general fire safety on 3/17/2022. Direct Service Worker #2, date of hire 8/02/2021, was instructed in general fire safety on 4/19/2022.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.All new staff hired, and clients as appropriate, will be instructed on general fire safety and in the use of fire extinguishers. This training will be conducted by the Human Resources department and coordinated with the initial onboarding process. Annual training will be provided to all team members by the organization. 07/01/2022 Implemented
2390.48(a)(3)Direct Service Worker #1, date of hire 8/16/2021, has no record of completing an orientation training. Direct Service Worker #2, date of hire 8/02/2021, has no record of completing an orientation training.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.Provider's Plan of Correction: Provide documentation of completed Orientation Training by direct service #1 and #2. 07/01/2022 Implemented
SIN-00187397 Renewal 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)-2The written record for the fire drill held on 3/4/2021 does not include the hypothetical location of the fire drill.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.On August 10, 2020 our program moved from our previous location at 1323 Forbes avenue, which we owned, to our current location at 2403 Sidney Street in the Southside, which we lease. Since we are now leasing, our maintenance director no longer coordinates fire drills and thus the form was not fully completed. On May 24, 2021 the Director of Facilities & Corporate Secretary, Director of Business Services, and the Director of Client Services reviewed our fire drill procedure to ensure that the form will be completed properly including the hypothetical location. 05/24/2021 Implemented
2390.87Chief Executive Officer #1 was instructed in general fire safety and in the use of fire extinguishers most recently on 4/9/2019. Program Specialist #2 was instructed in general fire safety and in the use of fire extinguishers on 3/27/19 and again on 5/10/2021.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.Due to mandated closures from the pandemic, Life¿sWork did not conduct a fire safety training for the staff in 2020. We do realize that we should have conducted a training once the facility opened back up. The Director of Client Services will ensure that the Chief Executive Officer will complete the fire safety training by 6/30/2021. 06/30/2021 Implemented
2390.49(c)(2)The annual training hours for the training year from 7/1/2019 to 6/30/2020 for Chief Executive Officer #1, Program Specialist #2, Direct Service Worker #3 and Program Specialist #4 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The detection and reporting of abuse is typically reviewed during our incident management training. However, due to the scope of the trainings available through the myodp website, the Director of Client Services will ensure that all staff take those trainings, which will be completed by 6/30/2021. 06/30/2021 Implemented
2390.49(c)(3)The annual training hours for the training year from 7/1/2019 to 6/30/2020 for Chief Executive Officer #1 and Program Specialist #2's did not encompass client Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights.Program Specialist #2 did complete the training on client rights on May 3, 2021. The certificate from the training will be submitted as proof. The Director of Client Services will ensure that the Chief Executive Officer will receive the training by 6/30/2021. [Certificate of achievement for Program Specialist #2 was provided to the Department on 5/26/21.] 06/30/2021 Implemented
2390.49(c)(4)The annual training hours for the training year from 7/1/2019 to 6/30/2020 for Chief Executive Officer #1 did not encompass recognizing and reporting Incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The Director of Client Services will ensure that the Chief Executive Officer will complete the training on Recognizing and Reporting Incidents by 6/30/2021. 06/30/2021 Implemented
SIN-00174457 Initial review 07/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.59The telephone numbers of the nearest police department, fire department and ambulance were not posted by the telephone in the office area.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephoneTelephone numbers of the nearest police department, fire department and ambulance service will be posted by the phones on Thursday, August 6, 2020 by Chris Phelps, Director of Client Services. A picture of the posted numbers will be sent to Amy Scharpf. [Photo of telephone with required telephone numbers submitted to and received by the Department. Upon admission and hire, all staff and individuals will be educated on the location and use of the telephone system and the posted telephone numbers. At least quarterly, a designated staff person shall check to ensure required telephone numbers continue to be posted by all telephones in the facility. (DPOC by AES,HSLS on 8/6/20)] 08/06/2020 Implemented
2390.75(b)(2)The dining area did not have chairs.A facility shall have a dining area for lunches and breaks. The area shall be clean and have dining tables and chairs. The dining area shall have a sufficient number of tables and chairs to accommodate the maximum number of clients scheduled for lunch or break.The dining area now has chairs. Pictures of the dining area with chairs was sent to Amy Scharpf by Chris Phelps, Director of Client Services, on Tuesday, August 4, 2020. [Photos of chairs submitted to and received by the Department. At least quarterly, a designated staff person shall check to ensure dining areas are clean and have tables and chairs sufficient to accommodate the clients for lunch and breaks. (DPOC by AES,HSLS on 8/6/20)] 08/04/2020 Implemented
2390.82(a)The written emergency evacuation diagram specifying directions for egress in the event of an emergency was not posted in the work area.Written 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.Three emergency evacuation diagrams specifying directions for egress in the event of an emergency were posted in the work area. Pictures of the posted diagrams were sent to Amy Scharpf by Chris Phelps, Director of Client Services, on Tuesday, August 4, 2020. [Photos of evacuation routes submitted to and received by the Department. Upon admission and hire, all staff and individuals will be educated on the location of the evacuation routes and the written emergency evacuation procedures including the evacuation diagram specifying directions for egress in the event of an emergency. At least quarterly, a designated staff person shall check to ensure evacuation routes are posted as required. (DPOC by AES,HSLS on 8/6/20)] 08/04/2020 Implemented
2390.193(d)The first aid kit contained a variety of single packet medications including but not limited to: Bayer aspirin, Aleve, Day Quill, Mucinex, cough Drops, acetaminophen and ibuprofen. In addition, the agency's medication policy stated medications were not administered.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The medications have been removed from the first aid kit. A picture of the first aid kit without the medications was sent to Amy Scharpf by Chris Phelps, Director of Client Services, on Tuesday, August 4, 2020. [Photos of first aid kit submitted to and received by the Department. Upon hire, all staff shall be educated on the location of the first aid kit and the facilities medication administration procedures. At least quarterly, a designated staff person shall check the first aid kit to ensure all required items are present and there are not unlocked medications. (DPOC by AES,HSLS on 8/6/20)] 08/04/2020 Implemented