Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257733 Renewal 12/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At 12:49PM, an unlabeled, plastic spray bottle filled with a purple liquid was next to the microwave on the cabinet in the kitchen of the home. Staff interviews revealed that the liquid was Fabuloso.Poisonous materials shall be stored in their original, labeled containers. On 12/24/24, Staff #1 removed all unlabeled plastic spray bottles at the home. All poisonous materials are now stored in the original, labeled containers - Eff 12/24/24. On 12/30/24 all staff was trained on this procedure/system that has been implemented on 12/24/24. To ensure that this violation will not occur again a new chart of check list of poisonous materials has been implemented, eff 12/30/24. Staff #1 is responsible to make sure that this checklist is completed on a weekly basis. 01/20/2025 Implemented
6400.64(a)At 12:42PM, there several areas of rust and food splatter that covered the ceiling of the microwave in the kitchen of the home. At 12:47PM, a sticky black substance and what appeared to be mold and food splatter covered the shelves and walls inside a cupboard containing canned goods, seasonings and other non-perishable items that were stuck to the shelves in the kitchen of the home. At 1:01PM, sticky substances and spilled food and seasonings were throughout plastic drawers where canned goods and other non-perishable items are stored in the kitchen of the home.Clean and sanitary conditions shall be maintained in the home. On 12/24/24, the microwave has been removed and replaced with a new microwave in the kitchen area. This area is clean and free of any mold, sticky substances and food. On 12/30/24, all staff members were trained on this procedure/system that was implemented on 12/24/24. After each daily use of this microwave, it will be cleaned and checked on a daily basis. The evening shift will be responsible for ensuring that this is done daily. Staff will complete this checklist on a daily basis. Staff will complete a check off list to make sure that this new procedure is implemented. Staff #1, will check this list at the end of each week to ensure that this violation will not occur again-- eff 12/30/24. 12/30/2024 Implemented
6400.82(f)At 1:12PM, there was no trash receptacle and no towels in the bathroom on the second floor of the home. At 1:10PM, there was no trash receptacle in the bathroom on the first floor of the home.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. On 12/24/24, Staff #1, purchased and installed (2) new trash receptacles for the bathroom on the second floor of the home and one on the first floor of the home. A paper towels dispenser has been installed on the second floor along with a clean cloth towel. Trash receptacles will always be in the bathroom areas, effective 12/24/24. Staff #1 is responsible to make sure that all bathrooms have trash receptacles. All staff members were trained on 12/30/24. 12/30/2024 Implemented
6400.104The provider agency sent a letter to the local fire department on 11/14/2024, that does not include information about the Individual #1's need for assistance and the exact location of the bedroom. Individual #1's assessment, dated 5/17/2024, reads, "[Individual #1] must have full assistance to evacuate in the event of a fire."The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. On 12/26/24, Staff #1, sent a new letter to the local fire department on 12/26/24, indicating the location of the individual(s) exact location of the bedroom(s) of the individual(s) who need assistance evacuating in the event of an actual fire. Effective 12/26/24, Staff #1, will be responsible for checking on a monthly basis to ensure that the local fire department has the correct location of the individual(s) and the exact location of the bedroom(s) of the individual(s) who may need assistance evacuating in the event of an actual fire. On 12/30/24, all staff members were trained on this new procedure/system that has been implemented on 12/26/24. 12/30/2024 Implemented
6400.171At 12:41PM, five packages of assorted frozen meals with instructions to keep frozen were on the shelf in the refrigerator in the kitchen of the home. At 12:43PM, two packages of frozen meals and a three Uncrustables with instructions to keep frozen were on a shelf in a miniature refrigerator in the kitchen of the home. At 1:10PM, a partially eaten container of Welch's Jelly with a layer of a fuzzy substance that appeared to be mold was on the top shelf of the refrigerator in the kitchen of the home. At 12:52PM, three jars of Bertolli Alfredo sauce with expiration dates of 4/4/2018 were in a drawer in the kitchen of the home. At 12:56PM, a container of Salsa with a best if used by date of 4/9/2020 was in a drawer in the kitchen of the home. At 12:57PM, a jar of Cholula Hot Sauce with a best if used by date of 10/2019 was in a drawer in the kitchen of the home. At 1:02PM, two packages of Giant Eagle brand Navy Beans with a best if used by date of 2/23/2018 were in the drawer in the kitchen of the home. At 1:16PM, a package of Giant Eagle brand Colby cheese with an expiration date of 3/5/2024, a package of Giant Eagle brand Monterey Jack cheese with an expiration date of 2/23/2024, a partially eaten container of Philadelphia Cream Cheese with an expiration date of 11/27/2024 were in the refrigerator in the basement of the home.Food shall be protected from contamination while being stored, prepared, transported and served. On 12/24/24, Staff Members: removed all expired food items--frozen & unfrozen. All expired food has been placed in the trash. Eff 12/24/24, All expiration dates have been reviewed & will be reviewed on a weekly basis by the following Staff Members: using a weekly check off list. Staff #1 will be responsible to make sure that this checklist is completed correctly and timely. Effective 12/24/24, all food shall be protected from contamination while being stored, prepared, transported and served. On 12/30/24, all staff members were trained on this new procedure/system that has been implemented on 12/24/24. 12/30/2024 Implemented
6400.32(s)(1)Individual #1 has a keyed locking mechanism on his bedroom door. Individual #1 has not been provided a key to lock and unlock the door independently.Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.On 12/24/24, Individual #1 has been provided a keyed locking mechanism on his bedroom door. This Individual #1 now has a key to his bedroom to lock and unlock the door independently. On 12/30/24, all staff members have been trained on this procedure/system that has been implemented on 12/24.24. Staff #1 is responsible to ensure that all Individuals are provided a keyed locking mechanism for their bedroom door. 12/30/2024 Implemented
SIN-00200045 Renewal 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(c)The interconnected smoke detector on the second floor of the home is located inside a bedroom and not a common area or hallway.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. On 2/17/22, Staff, RS, installed (3) smoke detectors in the common areas on each floor. RS is responsible for the "Monthly Monitoring" of all these devices to ensure that they are operating properly. On 2/17/22, Staff, RS, will be responsible for monitoring the smoke detectors -- (1) Smoke detector is located on each floor. These smoke detector devices will be monitored on the 1st week of each month by RS at Star Quality Enterprises and this info will be recorded monthly in the "Smoke Detector" Log Book--effective 2/17/22. 02/17/2022 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 12/20/2021, did not include medical 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. Eff 2/17/22, All of the OLD physical examination forms have been removed from Star Quality Enterprises files. The new forms does include: "6400.141(c )(14) Medical information pertinent of diagnosis & treatment in case of an emergency." All staff members have been trained on this new form on 2/17/22. DJ will make sure that this info is always entered on the individual's physical examinations forms. 02/17/2022 Implemented
6400.165(g)Individual #1 had a psychiatric medication review on 8/31/2021 and then again on 12/21/2021.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Eff 2/17/22, SQE staff has been trained --- In order to remain in compliance DJ will be responsible for monitoring the psych appointments monthly to a make sure that all medications prescribed to treat symptoms of psychiatric illness there shall be a review by a licensed physician at least every 3 mos that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.--This monitoring info will be kept in the "New Psych Booklet" by DJ 2/17/22. 02/17/2022 Implemented
6400.166(a)(4)Individual #1 was prescribed Ketoconazole Shampoo with instructions to apply topically two times per week on 12/20/2021. The name of this medication was not on the February 2022 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Eff 2/17/22, the discontinued medication: Ketoconazole Shampoo was removed. In order to remain in compliance, RS will check weekly the MAR & all medications, to make sure that all medications must be listed on the MAR. The medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. All staff members were trained on 2/17/22. 02/17/2022 Implemented
6400.166(a)(5)Individual #1 was prescribed Ketoconazole Shampoo with instructions to apply topically two times per week on 12/20/2021. The strength of this medication was not on the February 2022 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Eff 2/17/22, In order to remain in compliance, RS, has removed the discontinued Ketoconzaole Shampoo, RS will check weekly the MAR & all medications, to make sure that all medications be listed on the MAR. The medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. Strength of medication. All staff members were trained on 2/17/22. 02/17/2022 Implemented
6400.166(a)(6)Individual #1 was prescribed Ketoconazole Shampoo with instructions to apply topically two times per week on 12/20/2021. The dosage form of this medication was not on the February 2022 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Eff 2/17/22, In order to remain in compliance, RS has removed the discontinued medication--Ketoconzaole Shampoo; RS will check weekly the MAR & all medications, to make sure that all medications are listed on the MAR. The medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. Dosage form. All staff members were trained on 2/17/22. 02/17/2022 Implemented
6400.166(a)(7)Individual #1 was prescribed Ketoconazole Shampoo with instructions to apply topically two times per week on 12/20/2021. The dose of this medication was not on the February 2022 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Eff 2/17/22, In order to remain in compliance, RS will check weekly the MAR & all medications, to make sure that all medications must be listed on the MAR. The medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. Dose of medication. All staff members were trained on 2/17/22. 02/17/2022 Implemented
6400.166(a)(8)Individual #1 was prescribed Ketoconazole Shampoo with instructions to apply topically two times per week on 12/20/2021. The route of administration of this medication was not on the February 2022 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Eff 2/17/22, In order to remain in compliance, RS, will check weekly the MAR & all medications, to make sure that all medications must be listed on the MAR. The medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of mediation. Route of administration. All staff members were trained on 2/17/22. 02/17/2022 Implemented
6400.166(a)(9)Individual #1 was prescribed Ketoconazole Shampoo with instructions to apply topically two times per week on 12/20/2021. The frequency of administration of this medication was not on the February 2022 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Eff 2/17/22, In order to remain in compliance, RS will check weekly the MAR and all medications, to make sure that all medications must be listed on the MAR. The medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. Frequency of administration. All staff members were trained on 2/17/22. 02/17/2022 Implemented
6400.166(a)(11)Individual #1's February 2022 Medication Administration Record did not include the diagnosis or purpose for Risperidone, Trazodone, Lisinopril, Divalproex and Oxybutynin. Individual #1 was prescribed Ketoconazole Shampoo with instructions to apply topically two times per week on 12/20/2021. This diagnosis or purpose of this medication was not on the February 2022 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Eff 2/17/22, RS reviewed all medication records that are kept at SQE - Revisions have been completed -- Now it includes the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. -- DJ & RS is responsible to make sure that this information is entered on the MAR. This information will be checked on a weekly basis by DJ & RS. All staff members have been trained on 2/17/22. 02/17/2022 Implemented
SIN-00184674 Renewal 03/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 10/15/2020, had a criminal background check requested on 10/28/20.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.Effective immediately, 3/29/21, RS, Program Specialist, will be responsible to make sure that all prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals obtain an application for a Pennsylvania criminal history record check submitted to the State Police for prospective employees, within 5 working days after the person's date of hire. RS has developed a spread sheet/tracking system to make sure that all hire dates are in compliance with all regulatory rules and regulations. This new plan of correction will prevent the occurrence of this event from happening again. 03/29/2021 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 1/6/2021 does not include medical 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. Effective immediately, 3/29/21, RS has revised our current "individual physical examination" form to include: "6400.141(c) (14) Medical information pertinent to diagnosis and treatment in case of an emergency." All staff members have been trained on this new form on 3/29/21---Staff will make sure that this information is always entered on the individuals physical examination forms. 03/29/2021 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 6/16/2020 to the individual plan team members on 8/11/2020 for the individual plan meeting on 8/11/2020.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Effective immediately, 3/29/21, the program specialist has developed a new spread sheet tracking form for our individual's assessments to ensure that the program specialist provides the assessment to the individual plan team members at least 30 days prior to an individual plan meeting. This spreadsheet will be reviewed on a quarterly basis by RS, program specialist, to ensure that all assessments are provided within the regulatory guidelines of 30 days prior to the individual's plan meeting. 03/29/2021 Implemented
SIN-00169171 Renewal 01/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Direct Service Worker #1 was trained in fire safety on 1/15/18, and then again on 8/31/19.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Direct Service Worker #1 has been trained in fire safety on 1/6/2020, a new training chart has been established to ensure that all members of SQE are properly trained within the annual time frame. R SImpson will be responsible to make sure that this is completed. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned chart and all staff persons current and past fire safety training documentation to ensure timely completion of fire safety training. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/10/2020)] 01/29/2020 Implemented
6400.106The furnace was inspected and cleaned on 9/19/18, and then again on 11/2/19.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. As of 1/29/20, an annual furnace check chart has been established to ensure that the annual time frame is kept and R Simpson will be responsible to ensure that the furnace is checked on an annual basis. 01/29/2020 Implemented
6400.151(c)(2)Chief Executive Officer #2 had a Tuberculin testing most recently completed 11/18/17. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if 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, licensed physician's assistant or certified nurse practitioner. The Chief Exec Officer #2 has completed a Tuberculin testing and going forward D. Johnson will be responsible to make sure that all staff members of Star Quality Enterprises has completed their testing within the 2 year period and a time chart has been established to ensure that this time frame has been met.[At least quarterly for 1 year, the CEO or designee shall audit the aforementioned chart and all staff persons current and past Tuberculin testing documentation to ensure timely completion of Tuberculin testing. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/10/2020)] 01/29/2020 Implemented
SIN-00149834 Renewal 01/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The agency, Star Quality Enterprises will complete the self-assessment of each home within the requirements of 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. [Immediately, the CEO or designee shall complete a self-assessment of the home. Immediately, the CEO or designee shall review the current certificate of compliance and determine the dates 3 to 6 months prior to the expiration and develop a tracking and reminder system to complete the self-assessment within the required time frame. Prior to 3 months of the expiration date the CEO shall audit the self-assessment to ensure the self-assessment is completed fully and within the required time frames. The CEO shall sign off on the self-assessment to show an audit of the self-assessment has been completed. Within 30 days of receipt of the plan of correction, the CEO shall train all staff persons responsible for assisting in completing the self-assessment on their responsibilities. Documentation of the training shall be kept. (DPOC by AES,HSLS on 4/18/19)] 02/01/2019 Implemented
SIN-00106756 Initial review 01/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101There was a pad lock on the door leading from the kitchen to the basement. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The change to be made will consist of removing the pad lock from the door leading from the kitchen to the basement. The CEO made the change. The change was made on January 23, 2017. The change was made by completely removing the pad lock from the door. SQE will implement a procedure of requiring prior CEO approval of any changes or alterations being made to any doors or exits, stairways, passageways from rooms and/or building (residence). [Prior to working in the home, all staff shall be educated that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor for obstructions throughout the normal course of their daily duties. (AS 1/24/17) 01/23/2017 Implemented
SIN-00237089 Renewal 01/04/2024 Compliant - Finalized
SIN-00218010 Renewal 01/27/2023 Compliant - Finalized
SIN-00128577 Renewal 01/17/2018 Compliant - Finalized