Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241802 Renewal 04/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)A bottle of alcohol-based hand sanitizer was found in an unlocked cabinet in the program area.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The hand sanitizer was removed during the on-site inspection. All staff were trained where poisonous material is to be kept and reviewed the regulation. Signs were placed on all cabinets reminding that no poisonous materials are to be kept in unlocked cabinets or drawers. 04/17/2024 Implemented
2380.89(e)Fire drill records for the fire drills completed between March 2023 through February 2024 document that the "right-side CPS" door was used as the exit route for all drills. There are multiple exits in the facility and alternate routes were not used.Alternate exit routes shall be used during fire drills.An annual fire drill schedule was developed referencing routes to be used at each fire drill to ensure different exits are used throughout the year. The exit used will be documented on the Fire Drill Record. ((Fire Drill schedule will only be available to the staff responsible for running the drill to ensure compliance with 2380.89(a) referring to unannounced drills -CH 5/3/24)) 04/17/2024 Implemented
2380.181(a)The initial assessment for Individual #1 was completed late. Individual #1 was admitted to the program on 7/01/2023 and the initial assessment was not completed until 9/07/2023.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.The provider will update the consumer intake form checklist to include the date that the initial assessment is due. The intake checklist will be reviewed by the ID director at 30 days to ensure the initial assessment will be completed and in compliance with having initial assessments completed within 60 days of program start date. The ID director will review and sign the intake checklist at 60 days to ensure all required documents were completed. 04/17/2024 Implemented
2380.125(f)Individual #2 takes medication to treat the symptoms of a diagnosed psychiatric illness, and the provider did not have 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. The provider did write a social, emotional and environmental needs (SEEN) plan for the individual after the violation was discovered.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.the provider completed the SEEN plan at the time of the on-site inspection and provided to the inspector. 04/17/2024 Implemented
SIN-00222433 Renewal 04/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(c)A jar of peanut butter and a plastic container full of Clorox wipes were stored on the same shelf inside of a cabinet located in the program's conference room.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.The food item and cleaning product were removed and placed in a locked area and food item was moved to kitchen area.. 04/25/2023 Implemented
2380.59(a)At the time of inspection, the running water issuing from the sinks in both the Men's and Women's bathrooms was cold to the touch and did not warm even when the tap was allowed to run. Hot running water was unavailable in these two bathrooms.The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas.A phone call was placed to the plumber on April 27, 2023. They are scheduled to come to the facility on 5-16-2023 to adjust the water temperature in the facility bathrooms that have touchless faucets allowing them to run longer in order to raise the temperature. 05/16/2023 Implemented
2380.111(c)(5)Individual #1's two most recent Mantoux tests occurred on 02/15/2023 and 01/06/2021. The period between these tests exceeds the two years permissible by regulation.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.All physical and Mantoux dates will be monitored monthly to assure dates are met according to regulations and to remain in compliance. All current physicals will be checked to assure compliance. 04/26/2023 Implemented
2380.113(c)(2)Per staff employment records, Staff #2's most recent Mantoux test was placed 01/17/2023; however, there is no indication that this test was read after being placed and no record of a negative result.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.PYO has now set up directly with the medical provider to assure the paperwork is emailed the same day the physical/Mantoux is performed to avoid late or missed appointments. This particular staff did go to have the tb read but the medical office did not document the results. This staff has since gone back and has gotten another Mantoux test and resulted. 05/01/2023 Implemented
2380.181(a)Per the Individual Record, Individual #1's date of admission to the provider's facility was 07/22/2022. The Initial Individual Assessment for this individual was not completed until 10/14/2022, more than 60 days after the date of admission.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.All initial assessments will be scheduled at admission to be completed 60 calendar days from admission date. 04/27/2023 Implemented
2380.181(e)(3)(i)Individual #2's Individual Assessment, dated 01/26/2023, does not contain the individual's level of progress in the acquisition of functional skills. If the individual has not made progress in this area since they were previously assessed, the Individual Assessment should state that no progress has been made.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Acquisition of functional skills.All assessments will be reviewed by Program Specialists and ID director to assure levels of progress are noted in each assessment and "no Progress" will be noted if there are no changes in the persons acquisition of functional skills. 04/26/2023 Implemented
2380.181(e)(3)(ii)Individual #2's Individual Assessment, dated 01/26/2023, does not contain the individual's level of progress in the area of communication. If the individual has not made progress in this area since they were previously assessed, the Individual Assessment should state that no progress has been made.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication.All assessments will be reviewed by Program Specialists and ID director to assure levels of progress are noted in each assessment and "no Progress" will be noted if there are no changes in the persons communication abilities.. 04/26/2023 Implemented
2380.181(e)(3)(iii)Individual #2's Individual Assessment, dated 01/26/2023, does not contain the individual's level of progress in the area of personal adjustment. If the individual has not made progress in this area since they were previously assessed, the Individual Assessment should state that no progress has been made.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Personal adjustment.All assessments will be reviewed by Program Specialists and ID director to assure levels of progress are noted in each assessment and "no Progress" will be noted if there are no changes in the persons personal adjustment. 04/26/2023 Implemented
2380.181(e)(3)(iv)Individual #2's Individual Assessment, dated 01/26/2023, does not contain the individual's level of progress in the area of personal needs with or without assistance from others. If the individual has not made progress in this area since they were previously assessed, the Individual Assessment should state that no progress has been made.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others.All assessments will be reviewed by Program Specialists and ID director to assure levels of progress are noted in each assessment and "no Progress" will be noted if there are no changes in the persons personal needs. 04/26/2023 Implemented
SIN-00204471 Renewal 05/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The hot water temperature exceeded 120 degrees. The hot water temperature was 123.4 degrees.Hot water temperatures in areas accessible to individuals may not exceed 120°F.On 5-16-2022 PYO called and requested Hal's plumping to come and reset our water temp. He did so on that day- On 5-31-22 he came back to check and the water temp is now at 118. We will check again in a month to assure that the temp remains at the desired temp. 05/31/2022 Implemented
2380.38(b)(2)Staff #1 and Staff #2 did not receive orientation training in 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), and the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The orientation 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.A new orientation and annual training sheet clearly stating Mandated reporting, Adult protective services and Older adults protective services act has been updated and will be used for all newly hired staff and reviewed annually with all current employees 05/16/2022 Implemented
2380.39(c)(2)Staff #3 did not receive annual training in 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), and 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.A new orientation and annual training sheet clearly stating Mandated reporting, Adult protective services and Older adults protective services act has been updated and will be used for all newly hired staff and reviewed annually with all current employees 05/16/2022 Implemented
SIN-00188654 Renewal 05/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(u)The rights for Individual #1, Individual #2, Individual #3 and Individual #4 were not updated to reflect the new Chapter 2380 regulations. The missing rights include: Make Choices/Accept Risks; Refusal of Activities; Privacy of Person/Possessions; Violation of Others' Rights; Resolve Differences; and Rights Modified.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.The individual rights form was updated reflecting each of the updated rights according to the new chapter 2380 regulations at the time of discovery by the licensing inspector. A copy of the updated form can be shown if requested. 05/18/2021 Implemented
2380.126(a)(10)Individual #5 takes Erythromycin (250mg) and Sucralfate (1gm) while in program. Administration times are not listed on his medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The medication form was updated to reflect the administration times at the time of discovery. In review of our computer program, (Therap) that we have recently began using for medication administration, we have decided to revert to paper medication logs that are easily read and completed by staff. A new medication log has been drafted with the administration times and all other mandatory documentation needed for all medication logs. 05/19/2021 Implemented
SIN-00154082 Renewal 05/01/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.62The emergency number lists by each phone do not include the nearest hospital or the number for poison control. (Note: Corrected at time of inspection.)Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.May 2, 2019, emergency numbers including local fire, police, hospital, position control and 911 medical emergencies were placed by all telephones in the facility with an outside line. 05/02/2019 Implemented
2380.72(a)An outside walkway on which individuals may need to evacuate had a table on it, which could obstruct passage of wheelchairs. (Note: Corrected at time of inspection.)Outside walkways shall be free from ice, snow, obstructions and other hazards.May 1, 2019 the table and bench that partially obstructed the evacuation route were removed to the lower section of the sidewalk where there are no exits and no longer obstruct the evacuation route. 05/01/2019 Implemented
2380.111(c)(5)Individual #2 was admitted on 10-15-18, but did not have a TB test until 11-27-18.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.No individual will be admitted into the CPS program without a physical that meets the 2380 physical exam regulations. Sue Lattimer, Associate Director of Program will track and monitor all physicals of incoming individuals and monitor annual physicals of all CPS individuals to assure regulatory compliance. 06/07/2019 Implemented
2380.181(f)Individual #1's assessment was completed and sent to team members the same day the ISP meeting was held (04-08-18).The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).June 7, 2019 CPS assessment and annual ISP date tracking form was developed to track assessment dates to assure they are completed 30 days prior to the annual ISP date. June 10, 2019- The form was handed out to the program specialist to add in the dates and to begin using to track assessment dates. Sue Lattimer, PYO associate director of programs will monitor assessment and dates sent monthly. 06/10/2019 Implemented
SIN-00130500 Renewal 04/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(ii)Identifying marks were not listed in the records for Individual #1, Individual #2, Individual #3, Individual #4, and Individual #5.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Identifying marks were updated and corrected on individual records for Individual #1, Individual #2, Individual #3, Individual #4 and Individual #5. ((Program Specialist will review all individuals' records to ensure compliance - CH 5/16/2018)) 05/03/2018 Implemented
SIN-00111956 Renewal 07/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)The section pertaining to vision and hearing on Individual #5's physical form was left blank.The physical examination shall include: Vision and hearing screening, as recommended by the physician.2380.111(c)(4) documentation was requested and received regarding individual #5's vision and hearing screening. Information is attached to individual #5's physical Plan to prevent future occurrences- PYO physical form was updated to reflect all regulations regarding the physical requirements. If physical's are sent in without needed information, they will be returned to the dr asking for missing documentation. Sue Lattimer, Ron Myers and Gena Bond will be responsible to assure that all physicals are satisfactory and meet regulations. 08/14/2017 Implemented
2380.111(c)(5)The TB test for Individual #1 was conducted on 10/31/14 and not again until 11/16/16 which is outside the regulated time frame.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.2380.111(c)(5) tb test for individual #1 was not conducted within the regulated time frame. plan to prevent future occurrences.- A tracking system of physical and tb dates is in place. Letters are sent out 2 months in advance to assure physicals are scheduled in a timely manner by the family members and residential facilities. Reminders will be given 2 weeks prior to due dates to assure compliance with physical and tb regulations. Sue Lattimer, Ron Myers and Gena Bond will be responsible to assure there is follow up and compliance with physical and Tb dates. 08/08/2017 Implemented
2380.111(c)(8)There was no section addressing physical limitations on any of the five individual files reviewed.The physical examination shall include: Physical limitations of the individual.2380.111(c)(5) documentation was requested and received regarding all individuals addressing physical limitations. Information is attached to all individual's physical's. Plan to prevent future occurrences- PYO physical form was updated to reflect all regulations regarding the physical requirements. If physical's are sent in without needed information, they will be returned to the dr asking for missing documentation. 08/08/2017 Implemented
2380.111(c)(10)A section pertaining to information pertinent to diagnosis and treatment in case of an emergency was nowhere on any of the five individula files reviewed.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.2380.111(c)(10)documentation was requested and received regarding information pertinent to diagnosis and treatment in case of an emergency in all file individuals physicals. Plan to prevent future occurrences- PYO physical form was updated to reflect all regulations regarding the physical requirements. If physical's are sent in without needed information, they will be returned to the dr asking for missing documentation. Sue Lattimer, Ron Myers and Gena Bond will be responsible to assure that all physicals are satisfactory and meet regulations. 08/08/2017 Implemented
2380.181(e)(6)The ability to avoid poisons was not addressed in Individual #1's assessment.The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.2380.181(e)(6) - Assessment was updated to reflect individual 1's ability to safely use or avoid poisonous materials. plan to prevent future occurrences- all assessments have been revised with each assessment regulation number to assure all required information is included. Sue Lattimer, Ron Myers and Gena Bond will be responsible to assure all assessments have been updated. 08/31/2017 Implemented
2380.181(e)(7)Knowledge of heat sources was not addressed anywhere in Individual #1's assessment.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.2380.181(e)(7). Assessment for individual #1 was updated to include the knowledge of heat sources. Each individual assessment has been revised with assessment regulation numbers to assure all required information is included in each assessment. Sue Lattimer, Ron Myers and Gena bond will be responsible to assure this plan of correction is followed. 08/31/2017 Implemented
2380.181(e)(8)The individual's ability to evacuate in a fire was not addressed anywhere in Individual #1's assessment.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.2380.181.(e)(8) - The assessment for individual #1 was corrected to reflect the individuals ability to evacuate in a fire. All assessments have been updated with regulatory assessment numbers to assure that each has the required information included. Sue Lattimer, Ron Myers and Gena Bond will be responsible to assure all assessments are updated. 08/31/2017 Implemented
2380.181(e)(14)The individual's knowledge of water safety/ability to swim was not addressed anywhere in Individual #1's assessment.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.2380.181 (e)(14)- The assessment for individual #1 was corrected to reflect the individuals knowledge of water safety/ability to swim. All assessments have been updated with regulatory assessment numbers to assure that each has the required information included. Sue Lattimer, Ron Myers and Gena Bond will be responsible to assure all assessments are updated. 08/31/2017 Implemented
SIN-00094707 Renewal 04/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)From 11/12/2015 to 2/14/2016, the monthly fire drill sheets did not document which exit routes were used. 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.Violation 2380.89 (c) POC- The fire drill records not in compliance were reviewed by the administrative staff. The fire drill record designee will review each fire drill record assuring all required information is correct, then will hand the fire drill record to the program specialist for a review and signature before filing. 05/27/2016 Implemented
2380.181(e)(12)There are no recommendations for training, vocational programming, and competitive community-integrated employment listed in this section for Individual #1, Individual #2, Individual #3, and Individual #4.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Violation 2380.181(e)(12) POC- The program specialist will add required information in regards to recommendations for training, vocational programming and competitive integrated employment to individual 1,2 and 3. The program specialist, Sue Scudder will also review and make corrections to all other consumer assessments in regard to this regulation. 05/31/2016 Implemented
2380.181(e)(13)(i)The assessment for Individual #1 did not include progress inthe area of health.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Violation 2380(e)13)I) POC- The program specialist, Sue Scudder will add required information in regards to the individuals health over the last 365 calendar days and current health. The program Specialist Sue Scudder will also review all other assessments of individual receiving services to assure reg 2380.181. (e) (13) is in compliance. 05/27/2016 Implemented
SIN-00078668 Renewal 04/02/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(d)Staff #1 was hired on 2/23/2015 and does not have record of receiving the following training: Introduction to Developmental Disabilities. Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.The employee hired, Nicole Hatch, did not receive initial training of people with disabilities and program planning and implementation has received the required training and is in compliance of regulation 2380-181(a).The personnel department has a regulatory checklist for all mandatory trainings required for all new employees. This check list will be implemented and signed off by the Program Specialist and the Executive director. 05/22/2015 Implemented
2380.111(a)Individual #1 received his annual physical on 1/17/2014 and again on 2/17/2015. Individual #1 was present at the program without his annual physical being updated. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Program Specialist for the ATF program, Sue Scudder will assure that all physical dates have been recorded on a tracking sheet that will ensure that all physical reminders will be sent out a month in advance to avoid late returns of consumer physicals. A tracking sheet will be implemented to assure that physicals have been returned in accordance to regulation 2380-111(a) 05/22/2015 Implemented
2380.181(a)Individual #2 began to attend the program on 11/17/2014. Individual #2 did not receive his initial assessment at the time of the inspection on 4/2/2015. 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.The Program Specialist, Sue Scudder will implement an assessment tracking tool to assure all new and established individuals initial and annual assessments are completed in accordance to regulation 2380-181(a). 05/22/2015 Implemented
SIN-00061708 Renewal 03/20/2014 Compliant - Finalized