Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00210468 Renewal 07/27/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(b)-1There was no record or documentation that fire alarm was checked in the month of November 2021.An employe trained in the operation of the equipment shall check the fire alarm monthly. This was an oversight completed by the person who previously reviewed fire alarm records. The person who previously reviewed this has transferred to another building. Program Specialists will now be taking care of this, and have been trained to ensure this is reviewed monthly. 09/06/2022 Implemented
2390.104(4)Individual #2's and Individual #3's record did not include medical information pertinent to diagnosis and treatment in case of emergency.Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency.Staffing inconsistency for Program Specialists have been a challenge at the Bethlehem location. For over a year, there has been only one consistent PS which may have contributed to oversight. Both PS have been trained on reviewing medical information, especially physicals provided by physicians to ensure they are completed in their entirety. 08/03/2022 Implemented
2390.151(e)(12)Individual #1's assessment dated 6/2/22, Individual #2's assessment dated 12/25/21, and Individual #3's assessment dated 9/9/21 did not provide recommendations for specific areas of vocational training or placement and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment.An old assessment form was mistakenly used. Program specialists have been re-trained on the proper form to use for assessments. The new assessment form has a space to document recommendations for specific areas of vocational training or placement and competitive employment. 08/03/2022 Implemented
2390.151(e)(13)(iii)Individual #1's assessment dated 6/2/22, Individual #2's assessment dated 12/25/21, and Individual #3's assessment dated 9/9/21 did not address or assess the individual's progress over the last 365 calendar days and current level in the area of personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.An old assessment form was mistakingly used. Program Specialists were re-trained and provided the assessmment form which documents the individuals progress over the last 365 calendar days and current level in the following areas: personal adjustment. 08/03/2022 Implemented
2390.21(u)Individual #1 was informed of their client rights on 10/16/21, Individual #2 was informed of their rights on 10/26/21, Individual #3 was informed of their rights on 10/29/21, Individual #4's was informed rights until 7/11/22, and Individual #5 was informed of their rights on7/12/22, but the rights have not been updated. The agencies rights haven't been updated to reflect the current Chapter 2390 regulations. The missing rights include client may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment, make choices/accept risks, refusal of activities, privacy of person and possessions, access to and security of possession, voice concerns, negotiate choices, and rights may not be modified in accordance with §2390.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the client or others.( Repeat Violation 10/15/21)The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.The clients watched an individual rights video on their admission day, but all individuals did not have a signed form documenting this. In addition, the current form was revised to include all of the indvidual rights documented on their sign off form. 08/03/2022 Implemented
2390.48(b)(3)Staff #1 date of hire was 5/16/22, Staff #2's date of hire was 6/27/22, and staff #3's date of hire was 6/6/22 and their orientations did not encompass client rights.The orientation must encompass the following areas: Client rights.The orientation window has since been completed for the staff members who did have a documentation for individual rights. They have been since been trained and completed the myODP training to ensure they are knowledgable on individual rights for consumers 08/03/2022 Implemented
SIN-00194510 Renewal 10/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Staff #1, #2 and #3 and Individual #1 and #4 were not trained in fire safety.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.The training documents were completed for the staff #1, #2, and #3. In addition, individual #1 has completed this required training. I have attached supporting documents for the listed individuals. Individual #4 is trained annually, as this is a licensing requirement. This worker also has attachments for these items as well. 01/10/2022 Implemented
2390.124(4)There was no record for Individual #4.. Individuals #1, #2, #3 and #5 did not have a written consent form.Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment.This information was not provided within original entrance records for Individual #5, as this worker started with the agency over 20 years ago. This worker did upload documents for this correction, and re-uploaded documents for the individuals #1, #2 and #3 upon notification of licensing violations. This document was attached to another file, and may have been overlooked. 01/10/2022 Implemented
2390.21(u)Individual rights were not reviewed with Individuals #1, #2, #3, #4, and #5.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.This was not completed during the 20-21 fiscal year, as all APS buildings were not aware of the training requirement for consumers. This worker has reviewed this information with all Program Specialists as a group and separately to ensure this will be completed in all buildings going forward. 01/10/2022 Implemented
SIN-00158468 Renewal 07/31/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.85(a)-2The fire drill documentation for fire drills held on 3/27/19 and 6/27/19 did not include the hypothetical location of the fires.A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation.Associate Director is responsible to complete the fire drills and maintain documentation of fire drill records. Associate Director had been trained on this regulation, but did not remember there were 2 separate forms used internally in order to assure compliance. Only one of the forms was being completed which inadvertently resulted in the hypothetical location of fire not being recorded. The AD was retrained on this regulation (attachment 1). He was also retrained on both of our internal record-keeping processes/forms: one for the fire alarm checks and one for the fire drills (which includes a space for hypothetical location). Director of Habilitation will review records of next three fire dills to assure ongoing compliance. 08/01/2019 Implemented
2390.151(a)Individual #1's initial assessment was completed late. Individual #1 was admitted on 3/05/19 and the initial assessment was not completed until 6/05/19.Each client 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 Associate Director of Habilitation is responsible for the Initial Assessment within 60 calendar days for new Participants. The AD was new to the position when this Individual started. While the AD had been trained on the regulation and responsibility, he completed the assessment based on memory that the regulation said 90-days, not 60-days. The AD has been retrained on this regulation (attachment 1). All Initial Assessments for new Participants were reviewed; all were completed within the 60-day time frame. To assure ongoing compliance, the Director of Habilitation will monitor when new Participants enter the program by running a monthly report in our electronic file system. For the next three new Participants, the Director will: 1) set a reminder for 50-calendar days after Admission Date; 2) alert Associate Director that the Initial Assessment is due within 10 days; and 3) follow-up with Associate Director to confirm the Initial Assessment was completed within 60 calendar days. 08/01/2019 Implemented
SIN-00134416 Renewal 06/28/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #6's annual fire safety training was late. He had it 10/27/16, then not again until 11/20/17.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.This individual was absent on the day of the large group fire safety training and struggled with sporadic attendance over the next several weeks. Program Specialists forgot to assure he received fire safety training on the first day he returned to work, resulting in the late fire safety training. Program Specialists were retrained on this regulation (see email). A 10% random sample of records was reviewed for compliance between 7/30-8/2/18 (see spreadsheet). All records had documentation that the Fire Safety Training (FST) was completed within the annual time frame. Our most recent FST was completed on 10/13/17. FST will be completed again in October 2018. Program Specialists will use a master attendance list to assure 100% of participants receive FST. Any Individual absent on the day of FST will receive the training within the 15-day grace period. In the event someone does not return to work within this time frame, they will receive the training on the first day they return to work. 100% of records will be reviewed between 10/13/18 and 10/28/18. 08/03/2018 Implemented
2390.151(a)Individual #2's assessment was late. One was completed on 02/12/17, then not again until 04/05/18.Each client 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.Our internal process for completing assessments with the 2nd quarter review typically works well to assure ongoing regulatory compliance. When the PS for this particular individual changed, the new PS forgot to make note of the date on the most recent assessment and operated under the assumption that it had been completed concurrent with the 2nd quarter review, as per our internal process. This error resulted in the current assessment being out of compliance with the annual time frame. Program Specialists were retrained on this regulation (see email). A 10% random sample of records was reviewed for compliance between 7/30-8/2/18 (see spreadsheet). All records had assessments completed within the annual timeframe. To monitor for ongoing compliance, the Associate Director will review 5 records per FY quarter (July-Sep, Oct-Dec, Jan-March, April-June) and document findings. 08/03/2018 Implemented
SIN-00117810 Renewal 07/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1 had an assessment completed on 10/29/2015. He didn't have another assessment until 11/29/2016, which exceeds the annual requirement. Individual #2 had an assessment completed on 8/11/2015. She didn't have another assessment until 9/13/2016, which exceeds the annual requirement.Each client 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 have been retrained on the assessment process, including the requirement that assessments be completed within one year (plus 15 day grace period) of previous assessment (see attached). To ensure ongoing compliance, Director of Habilitation will randomly select and review 3 records per quarter for one year. 08/09/2017 Implemented
SIN-00095651 Renewal 07/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.72(a)In the back of the program area, where the jellies are being labeled, the walkways were obstructed with a pallet. On the opposite end of the building, near the loading dock, there was a filled pallet in the walkway. Both of these areas creates a fall hazard. Passageways and work aisles shall be unobstructed at all times.In the jams and jellies area, yellow tape markings were placed more than 36" from the work space. Pallets are placed behind these markings so that the work area remains unobstructed. Supervisors were retrained to keep walking aisles clear of obstructions as per regulation 2390.72. Yellow paint was used to more clearly delineate the walking aisle from the loading dock area. Documentation, including pictures, to follow. 08/04/2016 Implemented
SIN-00227371 Renewal 07/13/2023 Compliant - Finalized
SIN-00077517 Renewal 06/11/2015 Compliant - Finalized
SIN-00061639 Renewal 04/25/2014 Compliant - Finalized
SIN-00047622 Renewal 04/24/2013 Compliant - Finalized