Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241026 Renewal 03/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(6)Individual #1's annual physical dated 8/18/23 does not indicate whether or not they are free from communicable diseases. Neither the "yes" or "no" option is circled on the annual physical.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.Program Specialist contacted the doctor's office on 03/21/2024 to correct the missing information in the physical document, and this was returned to CARES of Central PA completed via fax on 03/28/2024 (Attachment 1). 04/01/2024 Implemented
2380.181(e)(5)Individual #1's assessment dated 10/19/23 does not address their ability to self-administer medications.The assessment must include the following information: The individual's ability to self-administer medications.Program Specialist updated this section in the annual assessment and sent to the team on 04/01/2024 (Attachment 3). 04/01/2024 Implemented
2380.181(e)(7)Individual #1's assessment dated 10/19/23 does not address their knowledge of heat sources and the ability to sense and move away quickly from heat sources which exceed 120 degrees and are not insulated.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.Program Specialist updated this section in the annual assessment and sent to the team on 04/01/2024 (Attachment 3). 04/01/2024 Implemented
2380.181(e)(8)Individual #1's assessment dated, 10/19/23, does not address their ability to evacuate in a fire.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.Program Specialist updated this section in the annual assessment and sent to the team on 04/01/2024 (Attachment 3). 04/01/2024 Implemented
SIN-00224804 Renewal 06/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)At the time of the inspection, the water temperature in the women's restroom sink was measured at 130.6F, and in the men's restroom sink measured at 127.F.Hot water temperatures in areas accessible to individuals may not exceed 120°F.Currently, the water temperature at CARES of Central PA Day Programs is checked every month during the fire safety checks. CARES of Central PA Day Program Management will continue to check water temperature monthly as part of the monthly Fire Safety Checks. CARES of Central PA Management will continue to maintain contact with the landlord/church in regard to any maintenance being done on the building and subsequently will check the water temperature at every sink for the 5 days following the conclusion of maintenance. Please see "Attachment 1" for the new document CARES of Central PA Day Program Management will record the water temperatures on weekly in these situations. 06/05/2023 Implemented
SIN-00205729 Renewal 05/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #2 had a negative Tuberculin skin test result on 03/20/20 and not again until 04/08/22.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.Individual 2s last quarterly review letter was completed 03/09/2022 (attachment 1). It provided a due date for his TB test of 04/20/2022 which includes a 30-day grace period. Individual 2s next quarterly review letter will be sent 06/06/2022 to coincide with his quarterly review meeting scheduled for that date (attachment 2) .This letter provides a due date for his next TB test of 04/08/2024. 06/03/2022 Implemented
SIN-00190594 Renewal 07/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The hot water temperature measured at the kitchen sink was 125.2 degrees Fahrenheit at the time of inspection.Hot water temperatures in areas accessible to individuals may not exceed 120°F.CARES of Central PA has been taking monthly water temperatures and logging them on the Fire Systems Check Log since September 11, 2020 as part of a POC for another CARES of Central PA day program. Please see Attachment 2 for a copy of the documented water temperatures from September 2020-current. All temperatures have been below 120°F using the red thermometer (Attachment 3), and a new gray digital thermometer was purchased on 7/12/2021 and will be used for all future water temping to ensure accurate temperatures. 07/30/2021 Implemented
2380.111(c)(10)Information pertinent to diagnosis or treatment in an emergency is not indicated on Individual #2 annual physical form dated 3/26/21.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.On 6/15/2021 when Individual 2s physical was received, it was noted that there were blanks. A fax was sent to her doctor on 6/15/2021 (Attachment 6) requesting that the physical be filled out to completion. A response was not received, and another fax was sent to the doctor on 7/30/2021 (Attachment 7) with another request for the physical to be filled out to completion and returned ASAP. The completed physical will be filed in Individual 2s file at the day program upon receipt. Physicals will be collected from Individual 2 on an annual basis and shall not lapse. Reminders of this due date will be sent quarterly as part of her quarterly notes. 07/30/2021 Implemented
SIN-00167793 Renewal 08/07/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.55(d)A large, black, hexagon trashcan in the lunchroom/social hall part of the program are was not equipped with a lid to ensure the trash was covered to prevent the penetration of insects and rodents. The trashcan top had a hole, approximately 1 foot in diameter in it.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.The large black hexagon trach can previously located in the lunchroom/social hall part of the program has been removed. 10/12/2020 Implemented
2380.59(b)The individuals utilize the social hall/lunchroom area of their program to have monthly parties and eat at if they are in the building over lunch. A kitchen, that contained a kitchen sink, is attached to the social hall and can be utilized by participants as needed. The water temperature in the kitchen sink, accessible to individuals, reached 123.1 degrees Fahrenheit.Hot water temperatures in areas accessible to individuals may not exceed 120°F.The water was tested on 8/20/2020 and was 80 degrees. (Attachment 5) CARES of Central PA has adjusted Fire Systems Check Logs to include water temperatures. Water temperature at the day program will be taken monthly and documented on the attached sheet moving forward. (Attachment #8) All Program Specialists and Team Leads have been trained on the updated Fire Systems Check Logs on 9/11/2020. (Attachment #9) 10/12/2020 Implemented
2380.65The top and bottom steps, located on the exterior egress route off of the library, were not equipped with non-skid surfaces. Interior stairs and outside steps shall have a nonskid surface.Non-skid surfaces have been installed on the top and bottom step on the exterior egress route off of the library. (Attachments 6a and 6b) 10/12/2020 Implemented
2380.87(a)The fire alarm system in the building was not operable at the time of the inspection. The agency could not activate the entire building alarm, indicated they did not know how to activate the building alarm system, nor did they utilize this system for their fire drills. The program used single, smoke detectors that were not interconnected and placed throughout the building for fire drills. However, the smoke detectors could not be heard throughout the whole building when activated.There shall be an operable fire alarm system that is audible throughout the building.Interconnected smoke detectors have been installed in place of the single non-connected alarms. 10/12/2020 Implemented
2380.87(b)Individual #1 is Deaf, Blind and can't hear the fire alarm system/smoke detectors when activated to alert him in the event of a fire. According to a fact sheet in his record, it states that "{Individual #1} is unable to evacuate independently due to being deaf/blind. {Individual #1} is staffed at 1:1 ratio within arm's reach. When {Individual #1} needs to evacuate, he will be assisted by staff to the designated meeting place. {Individual #1} has a vibrating smoke detector which staff carries; staff activate vibrating smoke detector while out in the community using a remote." The fire alarm system in the building and each, single smoke detector in the building are not equipped so that Individual #1 will be alerted in the event of a fire when the smoke detectors and fire alarm system are activated.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.CARES of Central PA has purchased a transmitter and vibrating receiver for this individual to be used while at the day program. Please see (Attachment #10) for a copy of the receipt. Upon receiving this device, it will be wired into the existing system. The Program Specialist and DSP Lead have been trained on how to use this transmitter and vibrating receiver. (Attachment #11) All staff members who will work with this individual will be trained on this device prior to working with the individual. 10/12/2020 Implemented
2380.111(c)(3)Individual #1's immunizations record was not included with his 9/5/18 physical examination record that was obtained by the agency upon admission. The Geisinger print out obtained by the agency on 9/12/19 also did not contain an immunization record. His immunization record was not included on any other physical examinations obtained on 7/30/2020 or 8/6/2020. · Individual #2's 7/15/2020 physical does not include if she received a Diphtheria or Tetanus immunization.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1¿s doctor has been contacted and the immunization record has been requested on 8/17/2020. All physicals will be checked for the inclusion of immunization records prior to admission to the day program. A new process of how physicals will be reviewed for completion prior to acceptance will be implemented. All individuals who plan to attend CARES of Central PA Day Program will be required to submit a physical and TB test prior to starting services and annually thereafter. If a physical is submitted with blanks or is incomplete in any way, the physical will be faxed to the appropriate doctor¿s office for completion. The individual will not be permitted to attend the program until the completed physical has been received and reviewed by CARES of Central PA management. All Program Specialists have been trained on this new process. (Attachment #12) 10/12/2020 Implemented
2380.111(c)(7)REPEAT from 3/22/2019 annual inspection: Individual #1's 9/5/18 physical examination record did not include his health maintenance needs; the field was left blank. The provider stated that information included on said section of Individual #1's physical was added later, by agency Staff person #4 at some point after Individual #1 received his physical examination from his doctor. The date and name of person making the entry was not included on the document in the individual's record.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.A copy of Individual #1¿s 9/5/2018 physical was obtained by CARES of Central PA on 8/28/2019. Please see (Attachment 4) for a copy of the completed 9/5/2018 physical for Individual #1. A new process of how physicals will be reviewed for completion prior to acceptance will be implemented. All individuals who plan to attend CARES of Central PA Day Program will be required to submit a physical and TB test prior to starting services and annually thereafter. If a physical is submitted with blanks or is incomplete in any way, the physical will be faxed to the appropriate doctor¿s office for completion. The individual will not be permitted to attend the program until the completed physical has been received and reviewed by CARES of Central PA management. All Program Specialists have been trained on this new process. (Attachment #12) 10/12/2020 Implemented
2380.111(c)(8)REPEAT from 3/22/2019 annual inspection: Individual #1's initial 9/5/18 physical examination record did not include his physical limitations; the field was left blank. The provider stated that information included on the physical limitations section of Individual #1's physical was added later, by agency Staff person #4 at some point after Individual #1 received his physical examination from his doctor. The date and name of person making the entry was not included on the document in the individual's record.The physical examination shall include: Physical limitations of the individual.A copy of Individual #1¿s 9/5/2018 physical was obtained by CARES of Central PA on 8/28/2019. Please see (Attachment 4) for a copy of the completed 9/5/2018 physical for Individual #1. A new process of how physicals will be reviewed for completion prior to acceptance will be implemented. All individuals who plan to attend CARES of Central PA Day Program will be required to submit a physical and TB test prior to starting services and annually thereafter. If a physical is submitted with blanks or is incomplete in any way, the physical will be faxed to the appropriate doctor¿s office for completion. The individual will not be permitted to attend the program until the completed physical has been received and reviewed by CARES of Central PA management. All Program Specialists have been trained on this new process. (Attachment #12) 10/12/2020 Implemented
2380.111(c)(10)REPEAT from 3/22/2019 annual inspection: Individual #1's initial, 9/5/18 physical examination record did not include his information pertinent to diagnosis in case of emergency; the field was left blank. The provider stated that information included on said section of Individual #1's physical was added later, by agency Staff person #4 at some point after Individual #1 received his physical examination from his doctor. The date and name of person making the entry was not included on the document in the individual's record. · Individual #2's 7/15/2020 physical examination record also did not include information pertinent to diagnosis in case of emergency; the field stated "n/a" (not applicable). The individual's previous 5/28/19 physical states "mild MR" under the "Information pertinent to diagnosis/treatment in emergency". Additionally, Individual #2 has a diagnosis of Leukosytosis, an increase in the number of white cells in the blood that could be due to a varying number of underlying causes. This is information that is pertinent to know if treating the individual during an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A copy of Individual #1¿s 9/5/2018 physical was obtained by CARES of Central PA on 8/28/2019. Please see (Attachment 4) for a copy of the completed 9/5/2018 physical for Individual #1. Individual #2¿s physical on 5/28/2019 did not include the diagnosis of Leukosytosis in the section ¿Information pertinent to know if treating the individual during an emergency¿ as this was not deemed appropriate for this section by the examining physician or CARES of Central PA¿s RN. A new process of how physicals will be reviewed for completion prior to acceptance will be implemented. All individuals who plan to attend CARES of Central PA Day Program will be required to submit a physical and TB test prior to starting services and annually thereafter. If a physical is submitted with blanks or is incomplete in any way, the physical will be faxed to the appropriate doctor¿s office for completion. The individual will not be permitted to attend the program until the completed physical has been received and reviewed by CARES of Central PA management. All Program Specialists have been trained on this new process. (Attachment #12) 10/12/2020 Implemented
2380.111(c)(11)Individual #1's 9/5/18 physical examination record did not include his dietary needs; the field was left blank. The provider stated that information included on said section of Individual #1's physical was added later, by agency Staff person #4 at some point after Individual #1 received his physical examination from his doctor. The date and name of person making the entry was not included on the document in the individual's record.The physical examination shall include: Special instructions for an individual's diet.A copy of Individual #1¿s 9/5/2018 physical was obtained by CARES of Central PA on 8/28/2019. Please see (Attachment 4) for a copy of the completed 9/5/2018 physical for Individual #1. A new process of how physicals will be reviewed for completion prior to acceptance will be implemented. All individuals who plan to attend CARES of Central PA Day Program will be required to submit a physical and TB test prior to starting services and annually thereafter. If a physical is submitted with blanks or is incomplete in any way, the physical will be faxed to the appropriate doctor¿s office for completion. The individual will not be permitted to attend the program until the completed physical has been received and reviewed by CARES of Central PA management. All Program Specialists have been trained on this new process. (Attachment #12) 10/12/2020 Implemented
2380.181(e)(10)Individual #1's initial, 9/26/19 assessment did not include his current allergy information as it is listed on his 9/5/2018 and 4/26/2019 physical examinations. According to his physical examinations, he is allergic to Vancomycin and Codeine. His 2019 assessment only included his allergy to Vancomycin.The assessment must include the following information: A lifetime medical history.This has been corrected in Individual #1¿s annual assessment updated 3/30/2020 which indicates that Individual #1 is allergic to Vancomycin and Codine. This update was sent to the team on 3/30/2020 and will be signed upon his return to day program. (Attachment 3) CARES of Central PA's Program Specialists complete each individual¿s annual assessment within 30 days of their start of service, and annually thereafter. The Program Specialist working during the reporting period is no longer the Program Specialist at CARES of Central PA. All new Program Specialists will be trained on paperwork requirements and the Regional Director and/or Director of IDD Services will review paperwork quarterly to check for accuracy and completion. CARES of Central PA's new Program Specialist hired on 8/18/2020 has been trained on paperwork requirements for all individuals attending day program. 10/12/2020 Implemented
2380.181(e)(14)Individual #1' initial, 9/26/19 assessment does not include his ability to swim. The assessment states he is able to swim but also states that he needs physical prompts to be able to swim and while in the pool, he uses some type of floating device.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.This has been corrected in Individual #1¿s annual assessment updated 3/30/2020 which indicates that, as stated in his ISP, ¿¿Individual #1¿ enjoys swimming and is able to swim. While swimming `Individual #1¿ chooses to use some type of flotation device. He is supervised in water at all items and is never left unsupervised.¿. This update was sent to the team on 3/30/2020 and will be signed upon his return to day program. (Attachment 2) 10/12/2020 Implemented
2380.21(u)Individual #1 was admitted to the program on 9/3/2019. At the time of the 8/7/2020 inspection, the facility did not inform and explain the individual's rights and the process to report a rights violation to the individual. ·Individual #1's mother, his Power Of Attorney (POA), did not have Individual #1's rights and the process to report a rights violation reviewed with her until 9/27/19, 24 days after the individual's admission and outside the regulatory time frame. Additionally, The Department issued new regulatory rights, effective 2/3/2020, to be reviewed with the individual and persons they designate. At the time of the 8/7/2020 inspection, neither Individual #1 or their POA had the updated regulatory individual rights reviewed with them.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.Individual #1 is not currently attending CARES of Central PA Day Program due to COVID-19. A copy of the updated individual rights has been mailed to Individual #1 and his mother for their review and will be filed upon return. CARES of Central PA's Program Specialists review individual rights with all individuals prior to or on their first day of service, and annually thereafter. The Program Specialist working during the reporting period is no longer the Program Specialist at CARES of Central PA. All new Program Specialists will be trained on paperwork requirements and the Regional Director and/or Director of IDD Services will review paperwork quarterly to check for accuracy and completion. CARES of Central PA's new Program Specialist hired on 8/18/2020 has been trained on paperwork requirements for all individuals attending day program. 10/12/2020 Implemented
2380.155(a)Individual #1's initial, 9/26/19 assessment states that when riding around with his staff in the community, he is to ride in the back seat of the vehicle with the child safety locks engaged because he has a history of unbuckling his seat belt. The individual's individual plan does not include an approved restrictive component of his behavior support plan to support the use of child locks when riding in a vehicle.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 2380.154 (relating to human rights team), prior to use of a restrictive procedure.This has been corrected in Individual #1¿s annual assessment updated 3/30/2020 which indicates that, as stated in his HRT approved restrictive plan, he is staffed in a 1:1 within arm¿s reach staffing ratio while at day program, due to being deaf and blind, therefore being unable to understand traffic signs, not being able to hear approaching cars, and being vulnerable to victimization. This update was sent to the team on 3/30/2020 and will be signed upon his return to day program. (Attachment 1) 10/12/2020 Implemented
SIN-00151009 Renewal 03/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The hot water as measured at the time of the inspection was 124.7.Hot water temperatures in areas accessible to individuals may not exceed 120°F.The hot water will be at or below 120 degrees. 04/15/2019 Implemented
2380.62The telephone located in the staff office did not have emergency numbers posted.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.The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were placed on the telephone located in the staff office. All telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center will be posted on or by each telephone in the facility with an outside line. 04/15/2019 Implemented
2380.68There is no space provided for hanging coats and hats and storing personal belongings. It was stated that the individuals keep their belongings on their person.Space shall be provided for hanging hats and coats and storing personal belongings.Individuals have a coat rack and storage bin for storing their personal items. 04/15/2019 Implemented
2380.70(a)The facility does not have a first aid area with privacy; not separated by partition or privacy screen from the office.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.The first aid area has been moved upstairs where the partition screen can be pulled in the case of someone needing first aid. 04/15/2019 Implemented
2380.111(c)(4)Individual #2's 5/4/18 physical did not include hearing or eye site examination.The physical examination shall include: Vision and hearing screening, as recommended by the physician.All individuals attending day program will have a completed physical annually with Vision and hearing screening, as recommended by the physician noted. (Attachment #3) 04/15/2019 Implemented
2380.111(c)(7)Individual #1's 9/18/18 and individual #2 health maintenance section of his physical is blank.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.All individuals attending day program will have a completed physical annually with an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals noted. (Attachment #3) (Attachment #4) 04/15/2019 Implemented
2380.111(c)(8)Individual #2's physical was left blank for physical limitations.The physical examination shall include: Physical limitations of the individual.All individuals attending day program will have a completed physical annually with physical limitations of the individual noted. (Attachment #3) 04/15/2019 Implemented
2380.111(c)(9)Individual #2's physical was left blank for allergies.The physical examination shall include: Allergies or contraindicated medication.All individuals attending day program will have a completed physical annually with allergies or contraindicated medications noted. (Attachment #3) 04/15/2019 Implemented
2380.111(c)(10)Individual #2's physical was left blank for medical information pertinent to diagnosis and treatment.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.All individuals attending day program will have a completed physical annually with medical information pertinent to diagnosis and treatment noted. (Attachment #3) 04/15/2019 Implemented
2380.113(a)Staff #1's physical dated 2/8/17 was not completed at time of inspection.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.All staff persons will have a physical with tuberculin skin test with negative results ever 2 years, or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. (attachment #2) 04/15/2019 Implemented
2380.113(c)(2)Staff #1's tuberculin skin test was completed on 2/11/17 and not completed again at time of inspection.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.All staff persons will have a physical with tuberculin skin test with negative results ever 2 years, or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. (attachment #2) 04/15/2019 Implemented
2380.173(9)Individual #1's ISP dated 11/9/18 states staff need to sit next to him while he is eating. He eats quickly and puts a lot of food in his mouth at once. Kenny is a chocking risk. Staff provide Kenny reminders to swallow bites of food before taking another bite. He often puts too much food in his mouth. The assessment dates 12/5/18 states 15 minutes alone time for the restroom. The ISP does not.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Individual #1¿s track changes were completed and sent to the support coordinator on 4/15/2019 to indicate the individuals need for supervision while eating. (Attachment #5) 04/15/2019 Implemented
2380.186(b)Individual #2's 12/4/18 ISP review was not dated by the program specialist or the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The program specialist and individual have signed the ISP review for the date reviewed. (attachment #1) 04/15/2019 Implemented
SIN-00131636 Renewal 03/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.57The office door egress was not equipped with an exterior light to assure safety and to avoid accidents.Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.A light was placed outside of the exterior office door on March 6, 2018. (Attachment: # 12) 03/06/2018 Implemented
2380.70(c)The upstairs program area was not equipped with a first aid kit.Each floor of the facility shall have a first aid kit accessible to staff persons.A first aid kit was put in the upstairs program area on March 6, 2018. Effective 4/9/2018 a first aid kit will be accessible to staff persons and be placed on each floor of the facility. 04/09/2018 Implemented
2380.84REPEAT from 1/18/17 renewal inspection: The facility had an onsite fire safety inspection of the building on 4/29/15 and not again until 11/29/17The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The onsite fire safety inspection is scheduled for November 2018, to be completed no later than November 30, 2018. Effective April 9, 2018, an onsite annual fire safety inspection shall be conducted by a fire safety expert. All documentation of the date, sources, and results from the fire safety expert shall be kept on file in the fire drill log at the day program. Each month the program specialist will ensure that a fire safety inspection is not needed for the following month. If an inspection will run out in the next month the program specialist will contact Eph Wiker, the Centre Region Code Administration Fire Inspector, to schedule a fire safety inspection. 04/09/2018 Implemented
2380.89(c)The written fire drill record did not indicated if the fire alarm was operative. The facility does not test the building fire alarm system monthly.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.Effective 4/9/2018, The program specialist will have a monthly fire drill. A written fire drill record will 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. (Attachment: #11) 04/09/2018 Implemented
2380.115(3)The written emergency medical plan did not include an emergency staffing plan.The facility shall have a written emergency medical plan listing the following: An emergency staffing plan.C.A.R.E.S. of Central Pa¿s Policy Manual has been updated to include a written emergency medical plan listing an emergency staffing plan. (Attachment: #10A &Attachment # 10 B) 04/09/2018 Implemented
2380.132(1)Written daily menus were not posted in the facility.If the facility provides or arranges for meals for individuals, the following requirements apply: Written daily menus shall be prepared and posted in a location visable to the individuals.Effective 4/9/2018, The program specialist will post a written daily menu including at least one item from the dairy, protein, fruits and vegetables and grain food groups. The menu will be posted at least 1 day prior to the meal being provided, in a location visible to the individuals. Attachment: #9 04/09/2018 Implemented
2380.132(6)According to the menus provided, there were many days over the previous two month period where the Friday meals did not contain at least one item from the dairy, protein, fruits and vegetables and grain food groups.If the facility provides or arranges for meals for individuals, the following requirements apply: Each meal served shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless medically contraindicated for an individual.Effective 4/9/2018, The program specialist will post a written daily menu including at least one item from the dairy, protein, fruits and vegetables and grain food groups. The menu will be posted at least 1 day prior to the meal being provided, in a location visible to the individuals. (Attachment: #9) 04/09/2018 Implemented
2380.173(9)Individual #1's record contained content discrepancy for who was the responsible party to make emergency medical consent decisions for Individual #1. His/her record indicated Individual #1 would make emergency medical decisions, also that his/her mother is responsible for emergency medical decisions and a residential staff is also responsible for emergency medical decisions. Individual #2's record also contained many different people that were responsible for making emergency medical decisions; Individual #2, his/her aunt and his/her brother. Individual #2's Individual Support Plan and identification sheet indicated he/she was allergic to Penicillin, Bactrim, dogs, cats, ragweed and dust. His/Her 8/3/17 physical examination only indicated allergies to Penicillin and Bactrim.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Effective 4/9/2018, Changes have been made to individual #1¿s record to reflect his Aunt making emergency medical consent decisions and his mother as a secondary emergency contact, as per the ISP. Changes have been made to individual #2¿s record to reflect her Aunt to be the primary contact, as per the ISP. Individual #2¿s physical examination has been corrected to indicate all of her allergies. The program specialist will insure each individual¿s records do not have discrepancies in the ISP, the annual update or revision under § 2380.186. If there are discrepancies the program specialist will send track changes to the SC. (Attachment: #8) 04/09/2018 Implemented
2380.181(b)Individual #1's 3/24/17 assessment indicated he/she required 1:1 staff to individual ratio with arms length supervision in the community. His/her supervision level changed on 8/1/17 to 1:1 staff to individual ratio with eye sight supervision in the community and he/she can use the restroom with staff outside the door. Individual #1's assessment was not updated to include the change of supervision needs.If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under §  2380.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section.Effective 4/9/2018 if the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 2380.186(c)(4), the individual shall have an assessment completed as required under this section. On 4/9/2018, Individual #1¿s team was sent, attachment #4, his updated supervision of individual ratio within eye sight supervision in the community and he can use the restroom with staff outside the door. 04/09/2018 Implemented
2380.181(e)(5)Individual #1's 3/24/17 assessment did not include his/her ability to self-administer medications. The Individual's assessment indicated he/she required assistance to select proper dosage of medication but that he/she could also self-medicate.The assessment must include the following information: The individual¿s ability to self-administer medications.Effective 4/9/2018, If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 2380.186(c)(4), the individual shall have an assessment completed as required under this section. individual #1¿s up-to date assessment of medication administration was sent, attachment #4. 04/09/2018 Implemented
2380.181(e)(9)Individual #1's 3/24/17 assessment did not include functional and medical limitations. The assessment did not address his/her medical limitations of having allergies to hay fever, Erythromycin and seasonal since the program is in the community/outside for most of the time. The assessment did not address his/her need for 1:1 staff to individual ratio in the community while attending the program due to inappropriate behaviors.The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.Effective 4/9/2018, The program specialist will include documentation of the individuals disability, including functional and medical limitations. Individual #1¿s up-to date assessment of his functional and medical limitations were sent, attachment #4. 04/09/2018 Implemented
2380.181(e)(10)Individual #1's 3/24/17 assessment did not include his/her lifetime medical history.The assessment must include the following information: A lifetime medical history.Effective 4/9/2018, The program specialist will include the lifetime medical history in the annual assessment. Individual #1¿s lifetime medical history was sent to his team, attachment #5. 04/09/2018 Implemented
2380.181(e)(13)(v)Individual #1's 3/24/17 assessment and Individual #2's 5/4/17 assessment did not include his/her current level and progress over the last 365 days in recreation.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Effective 4/9/2018, The program specialist will include the individuals progress over the last 365 calendar days and current level of skill in recreation. Individual #1 and #2¿s team was e-mailed with their progress over the last 365 calendar days and current level of skill in recreation. (Attachment: #6) 04/09/2018 Implemented
2380.181(f)Individual #1's 3/24/17 assessment was not sent to his/her plan team members. Individual #2's 5/4/17 assessment was not sent to his/her residential provider.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).Effective 4/9/2018, The program specialist will 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 and 2390.152, (relating to development, annual update and revision of the ISP). (Attachment: #7) 04/09/2018 Implemented
2380.186(b)Individual #2's 12/4/17 Individual Support Plan (ISP) was not dated by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Effective April 9, 2018 the program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. If the individual refuses to date a document the program specialist shall note that the individual refused to do so and put the date the individual signed. (Attachment # 1) 04/09/2018 Implemented
2380.186(c)(1)Individual #1's Individual Support Plan (ISP) reviews did not include participation and progress on his/her proper boundaries or employment skills outcomes. Individual #2's ISP reviews did not include participation and progress on his/her outcome of caring for myself.The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.Effective 4/9/2018, The monthly notes have been sent to individual #1 and #2¿s team members along with the quarterly ISP reviews. The ISP review will include a review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by C.A.R.E.S. of Central Pa under 2380 regulations. (Attachment: #2) 04/09/2018 Implemented
2380.186(c)(2)REPEAT from 1/18/17 renewal inspection: Individual #1's Individual Support Plan (ISP) reviews did not review his/her intensive 1:1 supervision level, behavior support plan or his/her protocol to address his/her social, emotional and environmental needs plan.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.On 4/9/2018 Individual #1¿s monthly notes have been sent, attachment # 2, to his team which review his intensive 1:1 supervision level, behavior support plan, and SEEN Plan. Effective April 9, 2018 quarterly notes will include a review of each section of the ISP specific to the individuals need while at C.A.R.E.S. of Central Pa. A quarterly note will review if applicable the Progress/Discussion/Issues, Progress with Outcomes, Review of SEEN Plan, Review of Restrictive Plan, and Attendance. (Attachment #2) 04/09/2018 Implemented
2380.186(d)REPEAT from 1/18/17 renewal inspection: Individual #1's Individual Support Plan (ISP) reviews were not sent to team members. Individual #2's 12/4/17 ISP review was not sent to his/her residential provider. Individual #2's 4/3/17 ISP review was not sent to team members until 5/19/17.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.Effective 4/9/2018 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. All ISP reviews from July 1 to present for individual 1 and 2 were sent to all team members on 4/9/2018. (Attachment #2) 04/09/2018 Implemented
2380.186(e)REPEAT from 1/18/17 renewal inspection: Individual #1's behavior support person and residential agency were not offered the option to decline his/her Individual Support Plan (ISP) reviews. Individual #2's residential provider was not provided the option to decline his/her ISP review documentation.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Effective 4/9/2018, The program specialist will notify the plan team members of the option to decline the ISP review documentation. Team members will also be given the option to decline on the quarterly review meeting sign in sheet. (Attachment #3) 04/09/2018 Implemented
SIN-00107840 Renewal 01/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The Fire Safety Inspection was completed on 4/29/15 and not again. It was due 4/29/16.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The annual fire safety inspection is scheduled for April 2017, to be completed no later than April 29, 2017. Eph Wiker is scheduled to conduct the fire inspection. Beginning April 2017, an onsite annual fire safety inspection shall be conducted by a fire safety expert. All documentation of the date, sources, and results from the fire safety expert shall be kept on file in the fire drill log at the day program. 01/18/2017 Implemented
2380.111(c)(4)Individual #1's physical dated 3/9/16 did not include information regarding vision and hearing screenings.The physical examination shall include: Vision and hearing screening, as recommended by the physician.All new individuals entering the program shall have a physical form that notates, by a licensed medical professional, if a vision and/or hearing screening was conducted and includes the results. If a vision and/or hearing screening were not conducted and are not necessary, this will be documented by the licensed medical professional on the physical form. All current individuals will return a completed physical form, signed by the licensed medical professional, documenting the same, upon their next annual physical. An individual will be granted 30 day leeway beyond their annual physical date to return the completed annual physical form. Non-completed forms, or failure to complete in full, will be returned to the individual and are to be completed and returned within that 30 day period. Any individuals that do not present a completed physical form within the 30 days will no longer be able to attend the program until such time as the required documentation is completed and returned to the program. 01/18/2017 Implemented
2380.111(c)(6)Individual #1's phyiscal dated 3/9/16 did not include information regarding whether or not he/she is free from communicable diseases.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease 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, to prevent the spread of the disease to other individuals.All new individuals entering the program shall have a physical form that notates, by a licensed medical professional, if the individual is free of communicable diseases. All current individuals will return a completed physical form, signed by the licensed medical professional, documenting the same, upon their next annual physical. If the individual is not free of a communicable disease, the licensed medical professional shall document specific precautions to be taken pursuant to section 28 in PA code 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting. An individual will be granted 30 day leeway beyond their annual physical date to return the completed annual physical form. Non-completed forms, or failure to complete in full, will be returned to the individual and are to be completed and returned within that 30 day period. Any individuals that do not present a completed physical form within the 30 days will no longer be able to attend the program until such time as the required documentation is completed and returned to the program. 01/18/2017 Implemented
2380.111(c)(7)Individual #1's physical dated 3/9/16 did not include an assessment of health maintenance needs, medication regimen and the need for blood work at recommended intervals. 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.All new individuals entering the program shall have a physical form that notates, by a licensed medical professional, an assessment of health maintenance needs, medication regimen, and required bloodwork and the recommended intervals. All current individuals will return a completed physical form, signed by the licensed medical professional, documenting the same, upon their next annual physical. An individual will be granted 30 day leeway beyond their annual physical date to return the completed annual physical form. Non-completed forms, or failure to complete in full, will be returned to the individual and are to be completed and returned within that 30 day period. Any individuals that do not present a completed physical form within the 30 days will no longer be able to attend the program until such time as the required documentation is completed and returned to the program. 01/18/2017 Implemented
2380.111(c)(8)Individual #1's physical dated 3/9/16 did not include information regarding physical limitations.The physical examination shall include: Physical limitations of the individual.All new individuals entering the program shall have a physical form that notates, by a licensed medical professional, any and all physical limitations of the individual. All current individuals will return a completed physical form, signed by the licensed medical professional, documenting the same, upon their next annual physical. An individual will be granted 30 day leeway beyond their annual physical date to return the completed annual physical form. Non-completed forms, or failure to complete in full, will be returned to the individual and are to be completed and returned within that 30 day period. Any individuals that do not present a completed physical form within the 30 days will no longer be able to attend the program until such time as the required documentation is completed and returned to the program. 01/18/2017 Implemented
2380.111(c)(10)Individual #1's physical did not include information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.All new individuals entering the program shall have a physical form that notates, by a licensed medical professional, any and all medical information that is pertinent to the diagnosis and treatment to the individual in case of an emergency. All current individuals will return a completed physical form, signed by the licensed medical professional, documenting the same, upon their next annual physical. An individual will be granted 30 day leeway beyond their annual physical date to return the completed annual physical form. Non-completed forms, or failure to complete in full, will be returned to the individual and are to be completed and returned within that 30 day period. Any individuals that do not present a completed physical form within the 30 days will no longer be able to attend the program until such time as the required documentation is completed and returned to the program. 01/18/2017 Implemented
2380.111(c)(11)Individual #1's physical dated 3/9/16 did not include special diet instructions.The physical examination shall include: Special instructions for an individual's diet.All new individuals entering the program shall have a physical form that notates, by a licensed medical professional, any and all special diet instructions for the individual. All current individuals will return a completed physical form, signed by the licensed medical professional, documenting the same, upon their next annual physical. An individual will be granted 30 day leeway beyond their annual physical date to return the completed annual physical form. Non-completed forms, or failure to complete in full, will be returned to the individual and are to be completed and returned within that 30 day period. Any individuals that do not present a completed physical form within the 30 days will no longer be able to attend the program until such time as the required documentation is completed and returned to the program. 01/18/2017 Implemented
2380.113(a)Staff#1 was hired on 6/6/16 but did not have his/her physical completed until 6/28/16.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.All new employees shall present completed physical form, signed by a licensed medical professional, on their first date of hire. No employee will be able to attend their orientation training without a completed physical form. All current employees will have a physical completed and signed by a licensed medical professional annually. The physical must be completed and returned to the agency within 30 days after the employees annual anniversary of the date of hire. 01/18/2017 Implemented
2380.113(c)(2)Staff #1 was hired on 6/6/16 and did not have his/her Tuberculosis test results read until 6/30/16.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.All new employees shall present completed physical form, signed by a licensed medical professional, that includes a tuberculin skin test, on their first date of hire. No employee will be able to attend their orientation training without a completed physical form. All current employees will have a physical completed and signed by a licensed medical professional annually and a tuberculin test completed bi-annually. The physical with a tuberculin test must be completed and returned to the agency within 30 days after the employees annual anniversary of the date of hire. The tuberculin test must notate a negative skin test. If a positive skin test is notated, then a chest x-ray, with results, must be notated. 01/18/2017 Implemented
2380.177Individual #1's record did not include a signed copy of consent to release information. There was a document for consent to release information however it was left blank.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.The consent to release information has been completed and signed by individual #1. Consent to release forms for all new individuals will be completed and signed upon entrance to the day program. 01/18/2017 Implemented
2380.186(a)Individual #1 started the program on 8/1/16 but did not have an Individual Support Plan (ISP) review completed until 11/30/16. One was due on 11/1/16. Individual #2 started attending program on 6/8/16 and did not have an ISP review completed until 10/3/16. One was due on 9/8/16.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 individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.All new individuals entering the program will have a 30 day ISP review meeting and then quarterly after that. The ISP review meeting will be conducted within 30 calendar days of attendance, rather than the previous 30 days of attendance. The quarterly ISP review meetings will be within 90 days thereafter the 30 day meeting. The quarterly ISP meetings will be conducted according to 90 calendar days. 01/18/2017 Implemented
2380.186(c)(2)Individual #2's Individual Support Plan (ISP) reviews dated 10/3/16 and 1/4/17 did not review his/her Social, Emotional, Environmental Plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Social, Emotional, and Environmental Plans will be implemented for all individuals who are prescribed psychotropic drugs by a licensed professional. S.E.E.N. plans will be constructed and reviewed by all direct support professionals prior to supervision of all new individuals. Individuals who already attend the program will have S.E.E.N. plans constructed, implemented, and reviewed by all direct support professionals by 02/20/2016. The S.E.E.N plan for individual #2, as mentioned in this violation, has a S.E.E.N. plan effective 01/19/2017. 01/19/2017 Implemented
2380.186(d)No documentation was found that Individual Support Plan (ISP) reviews for Individual #1 were sent to his/her team members and Support Coordinator (SC) within 30 days of the ISP review. No documentation was found that ISP reviews for Individual #2 were sent to his/her team members and SC within 30 days of the ISP review.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.Supports Coordinators received copies of ISP reviews, but documentation in reception were not notated. Effective 01/18/2017, ISP reviews will be accompanied by a letter to all team members. The letter will contain a c.c. (carbon copy) notation on the bottom left corner that notates all team members that the ISP documentation was forwarded to. The letter shall remain a part of the permanent programming files attached to the ISP documentation. 01/18/2017 Implemented
2380.186(e)Individual #1's record did not contain notification to his/her plan team members of the option to decline the Individual Support Plan (ISP) review documentation. Individual #2's record did not contain notification to his/her plan team members of the option to decline the ISP review documentation.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Option to decline forms have been added to programming files for all current individuals. It will be presented at the next scheduled quarterly meeting for all team members to sign. All new individuals entering the program will have an option to decline form to be signed by all team members. Option to decline forms will be presented at all ISP review meetings for changes. Former team members will be deleted and any new team members will be added. 01/18/2017 Implemented
Article X.1007Staff#1 hired on 6/6/16 and did not have a Pennsylvania criminal history record check. Staff#1 did have a Federal Bureau of Investigation criminal history record check completed but not until 6/28/16. Staff #2 hired on 8/31/16 did not have a Pennsylvania criminal history record check completed until 9/24/16. Staff#3 hired on 12/1/16 did not have a Pennsylvania criminal history record check completed until 12/10/16.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Staff #1 had completed a Pennsylvania criminal history record check, but the record results were not on file. Staff #1 completed an additional Pennsylvania criminal history check on 01/18/2017, that is now on file. New employees shall present a copy of their Pennsylvania criminal history check, Childline clearance, and Federal Bureau of Investigation clearance on their first date of hire. No employee will be able to attend their orientation training without a current copy of all clearances.. All current employees will have clearances conducted, as required by law, and will supply a copy of the records to the program. Any employees not presenting copies of required clearances within 30 days of the required date shall not be permitted to work with individuals until such time as the documentation is satisfied and presented to be kept on file. 01/18/2017 Implemented
SIN-00089509 Initial review 02/08/2016 Compliant - Finalized