Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228768 Renewal 08/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2, date of admission, 8-15-22, had an initial physical examination on 9-21-22.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Following the inspection on 8/3/23, all individual physicals were reviewed for completeness and accuracy. Any physical that has been identified as coming due has been communicated with the team to ensure they will be completed and turned in by the due date. 08/07/2023 Implemented
2380.111(c)(5)Individual #1's most recent Tuberculin skin test was completed on 1-21-21.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.Following the inspection on 8/3/23, Program Specialist contacted Individual #1 to schedule a Tuberculin Skin Test at a healthcare provider. Tuberculin test for Individual #1 was administered on 8/7/23 and negative results were read on 8/9/23. 08/09/2023 Implemented
SIN-00209149 Renewal 08/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #2 had physical examinations completed 1/18/21 and then again 6/2/22. [Repeat Violation-8/26/21]Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.All site participant physicals have been reviewed for completeness and accuracy up to this moment in time. Any that have been identified as coming due in the near future have been communicated with the team to ensure they will be completed and turned in prior to or on the due date. 09/01/2022 Implemented
2380.111(b)Individual #1's physical examination completed 10/19/21 is not signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.A signed copy of individual 1's physical has been obtained and all site participant physicals have been reviewed for completeness and accuracy up to this moment in time. 09/01/2022 Implemented
2380.111(c)(7)Individual #3's physical examination completed 7/27/22 does not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This is not a place on the form for this information.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The missing physical requirements have been requested of the team. The family indicated they will obtain the missing information and will provide it to the Program Specialist. All other site participants physicals have been reviewed for completeness. 09/01/2022 Implemented
2380.111(c)(9)Individual #4's physical examination completed 9/13/21 did not include contraindicated medication. This section was left blank.The physical examination shall include: Allergies or contraindicated medication.The missing physical requirements have been requested of the team. The family indicated they will obtain the missing information and will provide it to the Program Specialist. All other site participants physicals have been reviewed for completeness. 09/01/2022 Implemented
2380.113(c)(3)Direct Service Worker #1's physical examination completed 10/14/21 did not include a A signed statement that the person is free of serious communicable. This section was left blank.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.The staff physical due date tracking system was reviewed and updated to ensure dates are being tracked accurately as well as reminders being sent to staff in enough time for them to obtain an update physical and all of the required components. 09/01/2022 Implemented
2380.181(a)Individual #1, date of admission 11/30/21, had an initial assessment completed 2/1/22. Individual #3, date of admission 8/30/21, had an initial assessment completed 11/5/21.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 site participant assessments have been reviewed for completeness and accuracy up to this moment in time. Any that have been identified as coming due in the near future will be completed, signed, and distributed prior to or on the due date. 09/01/2022 Implemented
2380.181(f)Individual #1's assessment completed 5/17/22 was sent to the individual plan team members 5/17/22 for an annual ISP meeting held 5/4/22. Individual #2's assessment completed 1/12/22 was sent to the individual plan team members 1/12/22 for an annual ISP meeting held 1/11/22. Individual #4's assessment completed 11/17/21 was sent to the individual plan team members 4/12/22 for an annual ISP meeting held 4/12/22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.All site participant assessments have been reviewed for completeness and accuracy and compliant distribution up to this moment in time. Any that have been identified as coming due in the near future will be completed, signed, and distributed prior to or on the due date. 09/01/2022 Implemented
SIN-00192014 Renewal 08/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1's most recent physical examination was completed on 7-6-20.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.It had already been identified that Individual #1 did not have a physical in time. The Program Specialist had been in contact with the family and the appointment had been scheduled. The physical took place on 9/7/2021. During that appointment the doctor ordered blood work to be completed and they will sign off on the physical upon review of the bloodwork. Documentation of this is in the individual's book. Program Specialist will stay in touch with the family to ensure they submit the form as soon as the doctor signs off. 09/17/2021 Implemented
SIN-00164280 Renewal 10/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #1, date of admission 1/11/19, did not have an initial assessment completed. [Repeated Violation; 10/26/18]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.For Individual #1, an assessment was developed and distributed to the team on October 18, 2019. The Program Specialist confirmed an assessment is on file for all other Participants. Each Participant 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. Upon intake of a new participant, the program specialist will populate the tracker with the start date. Director will review tracker monthly and send out an email to Program Specialist with due dates of upcoming assessments. A calendar reminder has been added to the Director¿s calendar to do so the first Wednesday of each month. Documentation of the aforementioned audits will be kept by the Director. [At least quarterly for 1 year, the Director shall audit a 10% sample of individuals' current assessments to ensure the program specialist has completed assessments, timely. (DPOC by AES,HSLS on 10/25/19)] 10/18/2019 Implemented
SIN-00144044 Renewal 10/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)An unannounced fire drill was not held in June 2018.An unannounced fire drill shall be held at least once a month.A date will be selected and posted on the administration calendar (not visible to Direct Support Professionals or Participants). These dates will be projected out through the entire licensing year. A calendar post will also be projected out through the licensing year on the third to last business day of each month indicating that a Director will check with the Program Specialist to confirm a drill has been completed that month. If it has not been completed at that time, one will be completed, still to reflect the requirements of regulations. 11/08/2018 Implemented
2380.111(a)Individual #4 had a physical examination on 7-18-18, and the previous physical examination was completed on 6-12-17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The physical examination for Individual #4 was completed as of 7/18/18. Moving forward, the Program Specialist will ensure that physicals are done within 12 months prior to admission and annually thereafter. Upon receipt, physicals will be filed in the respective chart. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each physical has been updated as needed and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. This information will also be tracked on a participant information tracker that was implemented by September 11, 2018 as an extra measure to ensure compliance. 11/08/2018 Implemented
2380.181(a)Individual #3 , date of admission 7-10-18 had an initial assessment was completed on 10-24-18.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 initial assessment for Individual #3 was completed as of 10/24/18. Moving forward, the Program Specialist will complete an initial assessment for individuals within 60 calendar days after admission to the facility and an updated assessment annually thereafter. The assessments will be sent to the team members along with a cover letter and both documents will be filed in the respective chart. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each assessment has been updated as needed and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. This information will also be tracked on a participant information tracker that was implemented on September 11, 2018 as an extra measure to ensure compliance. 11/08/2018 Implemented
2380.181(e)(11)Individual #1's assessment, dated 1-3-18, did not include a psychological evaluation. Individual #2's assessment, dated 1-2-18, did not include a psychological evaluation. Individual #3's assessment, dated 10-24-18, did not include a psychological evaluation. Individual #4's assessment, dated 1-3-18, did not include a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable.Psychological evaluations have been requested for Individuals #1, 2, 3, and 4. They will be received and filed by 11/30/18. All other charts will be reviewed and a psychological evaluation requested, if applicable, by 11/12/18. Psychological evaluations will be reviewed upon receipt and assessments will be updated to include information regarding the same. The Assessment form has been updated to including a place to enter information regarding the psychological evaluation, if applicable. 11/30/2018 Implemented
2380.186(d)The program specialist provided Individual #1's ISP review documentation completed 8-31-18 to the plan team members on 10-10-18. The program specialist provided Individual #2's ISP review documentation completed 8-31-18 to the plan team members on 10-8-18.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.The ISP review documentation completed on 8/31/18 was sent to team members for Individual #1 and Individual #2 on 10/10/18 and 10/8/18 respectively. Moving forward, the Program Specialist will send ISP Review Documentation, including recommendations to the plan team members within 30 calendar days after the ISP review meeting. The documents will be filed in the respective chart. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure ISP review documentation has been completed and sent to team members and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. This information will also be tracked on a participant information tracker that was implemented on September 11, 2018 as an extra measure to ensure compliance. 11/08/2018 Implemented
SIN-00123828 Initial review 11/02/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)At 11:56 AM, the hot water temperature measured 139.8 degrees Fahrenheit at the sink in the women's restroom. Hot water temperatures in areas accessible to individuals may not exceed 120°F.The temperature on the hot water tank was adjusted on 11/2/17 after inspection. Temperature will be re-measured regularly and hot water tank will continue to be adjusted until temperature is below 120 degrees F. Director of IDD Services will review and monitor checks and ensure that temperature is below 120 degrees F prior to opening for services. Once services are being provided, the program specialist will test the temperature monthly in each restroom for a period of 6 months to ensure that the temperature does not exceed 120°F. The temperature will be recorded and maintained at the licensed facility and reviewed monthly by the Director of IDD Services. [On 11/3/17, hot water temperature measured 130.2, on 11/7/17 hot water temperature measured 122.4 and on 11/9/17 hot water temperature measured 118.9. At least weekly for 1 month and continuing monthly for at least 1 year, the program specialist shall measure the hot water temperature varying the areas that are accessible to individual to ensure the hot water temperature in areas accessible to individuals' do not exceed 120°F. Documentation of temperatures shall be kept and reviewed as stated above. (AS 11/13/17)] 11/10/2017 Implemented