Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00239511 Renewal 02/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.20(b)There is no attestation of residency stating whether or not new staff #1 or new staff #2 has lived within this Commonwealth for the 2 years prior to the date of hire to indicate whether or not an FBI check would need to be completed.If a prospective employe who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.A revised employee application has been created to include an attestation of residency within the Commonwealth for two years prior (attachment #1); CEO (who is hiring manager) will use this attestation to determine whether FBI (non-resident of PA in past two years) or PA State Police checks will be performed. 03/01/2024 Implemented
2380.89(e)Alternate exit routes were not documented on fire drills. The same exit was used for evacuation for all drills throughout the year. Plan of correction was initiated on the date of inspection by conducting a fire evacuation drill using an alternate route when the fire alarm was tested.Alternate exit routes shall be used during fire drills.Plan of correction began on the actual day of inspection, 2/1/24, while investigators were present at facility. An unannounced fire drill was performed, all staff and participants were directed to the side door/alternate exit and safely exited to proceed to the prescribed meet up space outdoors. All staff and participants received education on this topic and report understanding of the rule. Alternate exit will be used for at least 4 drills throughout each year. 02/01/2024 Implemented
2380.181(a)Individual #1's most recent assessment was completed on 2/19/23. The previous assessment was completed on 2/1/22. There were 384 days between assessments, exceeding the annual (365-day) requirement by 19 days.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.CEO has met with Program Specialist (PS) on two occasions since the inspection on 2/1/24 and have reviewed all participant files to check for this violation: no other violations were noted; all assessments were completed within 364 days. 03/04/2024 Implemented
2380.21(u)The review of individual rights was last completed with individual #1 on 1/17/23. There is no documentation of individual rights being reviewed in 2024 as of this inspection date, 2/1/24.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.Program Specialist (PS) reviewed individual rights with individual #1 on 2/16/24 and signed document has been filed. (Attachment #4). PS completed a file review of all participants and found two additional violations; each of these two participants met with PS by 2/16/24; documentation was placed in each file. CEO and PS have decided that documentation of review of individual rights will be completed for all participants by January 10 of each year. A column "review of individual rights" has been added to program specialist spreadsheet (attachment #3) to aid in compliance. 02/16/2024 Implemented
2380.181(f)There is no documentation in the record indicating that the program specialist provided the assessment for individual #2 to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Program Specialist (PS) emailed Individual #1's Supports Coordinator on 2/16/24, which is at least 30 days prior to individual plan meeting. (Attachment #7). PS reviewed all participant's files. Two additional violations were noted (assessments completed timely, but not submitted to SC in timely manner). PS emailed the the two participant's documents to their respective SCs by 2/28/24 and has placed documentation in each participant's file. 03/04/2024 Implemented
SIN-00219031 Renewal 01/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(c)Food items were stored in a locked closet along with cleaners.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.CEO will educate all staff that no foods are to be stored in any area that contains poisonous materials. All foods are to be removed immediately from locked storage cabinet containing cleaners and placed in the kitchen in cabinets. 02/20/2023 Implemented
2380.82A non-fire exit leading to the breezeway did not have a latch on the interior lock. Both sides of the lock were key enabled.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.Lock was replaced on 2/16/2023 . Photo sent to licensing. 02/16/2023 Implemented
2380.89(a)A fire drill was not completed for November 2022.An unannounced fire drill shall be held at least once a month.We had realized that we had not performed the fire drill for November 2022 on December 7, 2022. We immediately conducted an unannounced fire drill that day, Dec. 7, 2022. 02/10/2023 Implemented
2380.91(a)There is no fire safety training for Individual #2 or Individual #3.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Individuals #2 and #3 were instructed in English on February 1, 2023 about fire safety, were escorted through evacuation procedures on that day, instructed in fire drill responsibilities, shown in person the designated outside meeting safe place in the event of an actual fire (same area as fire drill safe space), and instructed in smoking safety procedures, which is at least 30 feet away from the building. A signed training record was emailed to Licensing. 02/01/2023 Implemented
2380.111(c)(10)Information pertinent to diagnosis and treatment in case of emergency is blank on the physicals for Individual #2 and Individual #3.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The RN/CEO will contact both individual #2 and #3 and guardians, ask them to contact physician/PCP and add medical information pertinent to diagnosis and treatment in case of emergency. 02/27/2023 Implemented
2380.39(c)(6)Verification that the annual plan implementation training was completed was not documented in the files for Staff #1 & Staff #2.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff #1 and Staff #1 completed the Foundations of ISP Development ODP module. Photos of training evidence sent to Licensing. 02/27/2023 Implemented
2380.123(d)The medication Clonazepam 2mg tablet prescribed to Individual #1 was stored in an unlocked bag in the program space.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.CEO will purchase locked containers for all prescription medications and syringes. The Clonazepam 2 mg. was placed in a locked container. A photograph of this medication and locked container will be sent to Inspector. 02/17/2023 Implemented
SIN-00174013 Initial review 07/14/2020 Compliant - Finalized