Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229478 Renewal 08/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual #1 did not have fire safety training over the last year.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 assigned Program Specialist completed Fire Safety Training with the individual upon his return to program since this discovery. 08/21/2023 Implemented
2390.102There should be at least a back-up for First aid staff that is trained in CPR. (If the two staff that is certified is not at the facility that puts the individuals in a compromising and/or harmful situation.At least one staff person certified in first aid techniques within the past 3 years shall be present when clients are at the facility. There shall be written documentation of the certification.(Director of CPS) works out of all APS locations and is trained in First Aid and CPR techniques. Director of CPS is the assigned back up first aid staff member that is trained in CPR should the two staff that are certified are not in attendance. 08/18/2023 Implemented
SIN-00210138 Renewal 08/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.72(a)There was a table placed up against a wall in a working aisle entryway that did not allow for 36 inches of space. The table was immediately removed after discovery to provided adequate space for passage.Passageways and work aisles shall be unobstructed at all times.The table was immediately removed by the building manager to ensure proper spacing in a working aisle. 08/16/2022 Implemented
2390.21(v)An annual signed statement acknowledging the receipt of the individuals rights did not contain the most current regulatory individual rights for individuals 1, 2, 3, 4, 5 and 6.The facility shall keep a copy of the statement signed by the client or the client's court-appointed legal guardian, acknowledging receipt of the information on client rights.The provided individual rights signature form did not provide all of the invididual rights as documented in the current regulations. The form has now been revised to include all of the individual rights documented in current regulations. Rights will be reviewed with all individuals in September and signed the same day as the agency fire safety training in October. 09/06/2022 Implemented
2390.153(c)There was no record of a sign in sheet or list that the ISP team participated in the annual team meeting for individual 4.The list of persons who participated in the individual plan meeting shall be kept.Program Specialists have been re-trained on obtaining a copy of a sign in sheet that the ISP team participated in the annual team meeting. 08/23/2022 Implemented
SIN-00191470 Renewal 08/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.62Sanitary conditions in the restroom close to the dinning area needs a thorough cleaning. (The tile throughout the restroom should be replaced).Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.A deep clean was completed to the bathroom, and the tiles on the floor will be replaced. 10/03/2021 Implemented
2390.70As there are hearing impaired employees on staff at APS McNulty, PA 2390 regulations require that this work facility have visible strobe lights in conjunction with the fire alarm system, that are visible throughout the facility. In the lunch/break area of this facility there are no strobe lights in the rear L-shaped portion of this room and adjoining staff microwave room. (Additionally, none of the other strobe lights in other parts of this building are visible if you are located in the L-shaped rear portion of this room.) Also, in the main work area of this work facility there are no eye level strobe lights. The only strobe lights in this area of the building are in the ceiling and do not illuminate on the walls or floor when flashing, creating a situation in which a hearing impaired individual could have their attention elsewhere and not see the ceiling height strobes delaying their exit time in the event of a fire.Equipment shall include magnified or otherwise modified visual, auditory and tactile signals if necessary for the individual client using the equipment.APS rents its McNulty building. The lease requires any changes to the fire alarm system be approved prior to completing. The fire alarm system also requires the wiring throughout be assessed prior to improving the strobe lights as outlined. T/his worker has emails documenting the request for an estimate with the landlord to begin the necessary re-wiring in the fire alarm system. 10/03/2021 Implemented
SIN-00169237 Renewal 01/13/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.62The microwaves through out the dinning area were not clean.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.On 1/14/2020, Program Specialists were retrained on this regulation (attachment 1). All microwaves were thoroughly cleaned on 1/14/2020 (attachment 2). APS has a contract with a cleaning company; this company cleans the microwaves weekly. APS also has Individuals who clean the dining area (tables, floors) every day after lunch. Starting 1/15/2020, Individuals who clean the dining area were also trained in cleaning the interior of the microwaves. This is now completed daily after lunch. In order to assure ongoing compliance, Associate Director will inspect microwaves (interior and exterior) twice per week; if microwaves are not cleaned adequately, Individuals will be immediately retrained on, and assisted with, thoroughly cleaning microwaves. 01/14/2020 Implemented
2390.85(a)-1The fire drill record on 6/12/19 had been altered with white out, and was unable to tell if it was incompliance.A fire drill shall be held at least every 90 calendar days. On 1/14/2020, Program Specialists were retrained on this regulation (attachment 1). Training included the proper way to document an error (1 line through error, initial). In order to assure ongoing compliance, Associate Director will review documentation of fire drills and alarm checks each FY quarter. 01/14/2020 Implemented
2390.87Individual #1's initial fire safety training was not dated.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.On 1/14/2020, Program Specialists were retrained on this regulation (attachment 1). On 1/14/2020, Director of Habilitation reviewed documentation for all new hires since Jan 1, 2019. All other records were compliant. In order to assure ongoing compliance, Director of Habilitation will review new hire records every FY quarter and document findings. 01/14/2020 Implemented
2390.151(a)Individual#3's assessment was not completed annually. Last annual assessment was completed 05/17/2018 and current was completed 08/13/2019.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.On 1/14/2020, Program Specialists were retrained on this regulation (attachment 1). Program Specialists will review all current and previous assessments for Individuals on their caseload by 2/14/2020 to monitor for compliance. Any areas of non-compliance will be documented and addressed. To assure ongoing compliance, Associate Director will monitor 3 Individual records per calendar month and document findings. 01/14/2020 Implemented
2390.156There was a discrepancy on the Individual plan for individual#2 between the annual review update date, and the date the plan was to be implemented as written by start date.The facility shall implement the individual plan, including revisions.On 1/14/2020, Program Specialists were retrained on this regulation (attachment 1). Retraining included: - look more carefully at the dates in the Outcomes section, as well as the content in the rest of the ISP, to assure accuracy and consistency - request revisions if any discrepancy is noted and document the request in the 3-month review Program Specialists will review all ISP's for Individuals on their caseload by 2/14/2020. If any discrepancies are noted, an email will be sent to the Supports Coordinator to request revisions. Associate Director will monitor 3 Individual records per FY quarter and document findings to assure ongoing compliance. 01/14/2020 Implemented
SIN-00091537 Renewal 03/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1's assessment dated 8/12/15 was more than a year from the previous assessment dated 9/4/13. Individual #2's admission date of 7/27/15 did not have an initial assessment until 1/6/16, which exceeded the 60 calendar days. 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.1. The Director of Habilitation was aware of performance deficits with the Program Specialist whose records were cited through regular oversight and monitoring. The Program Specialist was trained and retrained, received corrective actions and when all efforts failed, was terminated for inability to execute the duties of position. a. The Director of Habilitation has retrained all Program Specialists on the definition of "annual" per 2390 regulations which is 365 days + 14 as pertains to the completion of annual assessments. This was completed 4/8/16 (see attachment 1). b. All annual assessments will be completed within 365+14 days. c. Effective immediately all Program Specialists will add the initial step of pulling the previous year assessment to insure the new assessment is completed within 365+14 days. 2. The Associate Director of Habilitation will randomly sample at least one record from each Program Specialist case load quarterly for the next 12-months (April, July, October 2016 and Jan 2017) to insure compliance. 3. All Program Specialists have been retrained on the process and the Associate Director of Habilitation has been trained on the monitoring responsibilities (see attachment #1). 4. Please see attachment #3 which includes assessments from all current Program Specialists demonstrating the understanding of and ability to comply with regulation 2390.151(a). 04/08/2016 Implemented
SIN-00073661 Renewal 01/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.83(a)On 01/21/2015, the fire alarm was unable to be tested because the provider did not have the code to place the system on test due to the change in ownership of the building and alarm companiesThere shall be an operable fire alarm that is audible throughout the facility.If APS becomes aware of a change in any program location building management or ownership, we will be proactive and inquire about changes to the alarm management company so that there will be no break in our ability to effectively manage 2390 fire safety requirements. The CFO and all building managers have been informed of this POC. The maintenance department will test the fire alarms on a monthly basis to ensure that they alert the participants of the program of the possibility of a fire. In addition, the testing of the fire alarm will be noted on the fire drill record. 02/01/2015 Implemented
2390.124(1)Individuals #1, #2, #3, #4, #5, #6, #7 and #8's record did not include the individuals place of birth. Each client's record must include the following information: The name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge.Program Specialists will record the birth place of the individual and include it in the Lifetime Medical History record. If they are unable to ascertain this information, they will document the attempt and record as "unknown". Accurate documentation will included as part of the employee annual review. The Program Specialists has updated Individuals #1-#8's record to include their birthplace. The Program specialist will audit all of the participants records to ensure that all of the required elements of this regulation and that the birthplace was noted in the records. 02/01/2015 Implemented
2390.151(f)There was no documentation that Individual #2's annual assessment, dated 07/31/2014, was provided to the SC at least 30 days prior to the ISP meeting date of 08/25/2014. There was no documentation that Individual #7's annual assessment dated 01/30/2014 was provided to the SC at least 30 days prior to the ISP meeting date of 10/28/2014. There was no documentation that Individual #8's annual assessment dated 07/08/2014 was provided to the SC at least 30 days prior to the ISP meeting date of 08/29/2014. 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).All Program Specialists will complete the assessment annually and distribute at approximately 180 days prior to the ARU date, email it to the Supports Coordinator and plan team members and save a copy of the email as documentation. Nikki McCullen and all program specialists will insure compliance is met going forward. Program Specialists were trained on this Jan 7th when it was identified as a weakness. Program Specialists will either print the email and file or save it as a document in the electronic file and the Director of Habilitation will conduct random quarterly reviews of each PS through the 2015 calendar year. Retraining and employee corrective actions per company policy will be implemented as necessary. An auditing form will be developed, that tracks the dates of the ISP meetings and when the assessments are due, by the Program Specialist to ensure that all assessmens are forwarded to the Supports Coordinator at least 30 days prior to the ISP meeting. 12/01/2014 Implemented
SIN-00058798 Renewal 01/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)Individual #1's assessment dated 2/6/13 was not sent to the plan team. (f) 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).To insure compliance with 2390.151(f), all Program Specialists will document the distribution of the assessment to the team at least 30-days prior to the ISP meeting using either a distribution list on the assessment, a cover letter with a distribution list or a copy of the email. The Director of Habilitation has created a Standard Operating Procedure (SOP.H2) for the assessment process. All current Program Specialists will be trained on this SOP and new hires will receive it as part of their training, starting 2/1/14. The Director of Habilitaton will monitor for compliance monthly for the next 6-months and annually thereafter. 01/25/2014 Implemented
SIN-00045154 Initial review 02/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Individual # 1 did not have annual fire saftey training. His last training was completed on 10-7-12.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.Individual #1 and all individuals who transfer from one service location to another will be retrained in fire safety and a record will be kept with client file. 02/05/2013 Implemented
2390.153(5)Individual # 1's social, emotional and envirnomental plan was updated on 1-16-13 and there was no documentation of staff being trained on the new plan.(5) A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Documentation will be maintained by the agency of staff training on social, emotional and environmental support plans. 02/12/2013 Implemented
2390.156(a)Individual #3's ISP was held on 9-27-12 and the first quarterly review was not completed until 1-22-12.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.An individual¿s quarterly (90-day) review of the ISP will be completed and signed by the individual and the program specialist every 3-months using the ISP annual review update date as the starting point. 12/21/2012 Implemented
2390.156(b)Individual # 2's quarterly review dated 3-12-12 was not reviewed and signed by the individual.(b) The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.Both the program specialist and client will sign and date the quarterly ISP review sheet upon review of the ISP. 03/21/2013 Implemented
SIN-00116680 Renewal 06/29/2017 Compliant - Finalized