| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00276119
|
Renewal
|
10/17/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Light switches, door jams, and walls were visibly dirty throughout the house.
Two (2) throw rugs and a used mop were found inside the 1st floor bathroom shower stall.
Discarded furniture, trash and debris were found on the basement floor along the wall located to the left of the stairs and you come down the stairway. | Clean and sanitary conditions shall be maintained in the home. | All surfaces in the home, included but not limited to light switches, door jams & walls have been thoroughly cleaned.
Throw rugs have been returned to their right spots with the bathroom, while the mop has been returned to right spot with the mop bucket and other cleaning supplies.
Old furniture thats not In use have been properly discarded outside of the building, away from living areas, along with all trash & debris in the home. |
10/20/2025
| Implemented |
| 6400.67(a) | Two wall tiles next to the kitchen window have peeled away from the wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | Work order has been submitted to address peeled/missing wall tiles. |
10/24/2025
| Implemented |
| 6400.67(b) | The vent above the oven is missing a cover, exposing the interior fan and wiring.
The exterior doorstep leading to the side porch has rotting and splintered wood that requires repair.
The water fixtures to the 2nd floor bathroom were not secured to the shower wall; leaving gaps between the fixture and wall when turning the water on and off, and also allowing moisture to get behind the fixture when water was running. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The cover of the vent above the oven has been replaced and the interior fan and wiring are no longer exposed.
The exterior doorstep leading to the side porch has been repaired and no longer has rotting and splintered wood.
The water fixtures to the 2nd floor bathroom are now secured to the shower wall, and there are no more gaps between the fixture and wall, and moisture is not able to get behind the fixture anymore when it is in use. |
11/14/2025
| Implemented |
| 6400.68(a) | The water temperature in the 1st floor bathroom measured 94.5° and was warm to the touch.
The water in the 2nd floor bathroom measured 85.4° and was warm to the touch.
The hot water knob in the kitchen sink was labeled "C" for cold, and the cold water know was labeled "H" for hot. | A home shall have hot and cold running water under pressure. | Rehoboth inc Director increased the water heater temperature and the temperature in both bathrooms read 116 degrees.
The kitchen faucet has been correctly labeled. |
10/17/2025
| Implemented |
| 6400.70 | The home telephone located in the living room was disconnected and non-operable. This was corrected at the time of the visit. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| The home telephone located in the living room has been connected and now operable. |
10/20/2025
| Implemented |
| 6400.76(a) | The closet door in the 1st floor bedroom is broken, and the door is laying against the wall inside the closet.
The dresser in the 1st floor bedroom (vacant) has a broken drawer that is off track and cannot be properly opened and closed.
Four (4) dining room chairs were wobbly and unstable.
In the kitchen, the corner cabinet and cabinet under the window were both off track and could not be properly opened or closed. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The closet door in the 1st floor bedroom has been fixed.
The dresser in the 1st floor bedroom has been disposed and no longer in the home.
Dining room chairs have been tightened and are not longer wobbly/unstable.
The 2 kitchen cabinets in questions have been fixed and all other cabinets have been inspected to ensure they properly open & close. |
10/24/2025
| Implemented |
| 6400.77(b) | The home's first aid kit did not contain thermometer, an assortment of bandages, antiseptic, or tape | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Missing items in the home's first aid kit has been replenished. |
10/24/2025
| Implemented |
| 6400.80(b) | A section of several boards on the back porch were bowed. The boards were unstable and bounced when walking on them. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The back porch has been inspected and all faulty boards have been replaced/fixed and no longer bounce when walked on. |
10/31/2025
| Implemented |
| 6400.82(b) | The 1st floor bathroom did not have individual clean paper towels or cloth towels.
The 2nd floor bathroom did not have toilet paper, and none could be found in the bathroom closet, cabinet, or in the hallway closet.
The 3rd floor bathroom did not have individual clean paper towels or cloth towels. | There shall be at least one bathtub or shower for every four individuals for homes opened on or after March 15, 1982. There shall be at least one bathtub or shower for every six individuals for homes opened on or before March 14, 1982. | All bathrooms in the home have been equipped with paper towels, with extra paper towels also available in the supplies closet.
2nd floor bathroom has also been equipped with toiler paper, with extras also available in the supplies closet. |
10/24/2025
| Implemented |
| 6400.104 | There was no Fire Department Notification Letter on record for Individual 1. | 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.
| A current Fire Department Notification Letter has been received for Individual 1 & is present at the home. |
10/24/2025
| Implemented |
| 6400.111(f) | The fire extinguisher on the 3rd floor did not have a tag to show it was inspected annually by a fire safety expert. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher on the 3rd floor has been re-inspected and the tag showing the date it was inspected is now attached. |
10/20/2025
| Implemented |
| 6400.112(d) | The 8/07/25 Fire Drill noted an evacuation time of 2 minutes and 45 seconds, which exceeds the maximum time allowed. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Individuals have been trained/educated on safely & successfully evacuating the building in case of a fire, within 2 minutes. This has been done before, and in addition to, the next unannounced monthly fire drill. During the next unannounced fire drill, both individuals were able to evacuate the entire building within 2 minutes. |
10/20/2025
| Implemented |
| 6400.216(a) | Individual Support Plans (ISP's) for Individual 1 and Individual 2 were being kept on a table in a common room area, and should be kept locked. | An individual's records shall be kept locked when unattended.
| All ISPs have been moved to binder in a locked cabinet and no documents containing individuals' records are kept unlocked when not in use. |
10/17/2025
| Implemented |
| 6400.165(a) | Four packs of non-aspirin pain reliever tablets were found in the home's first aid kit, and all medications, including prescription and over the counter medications, shall be prescribed in writing by an authorized prescriber. | A prescription medication shall be prescribed in writing by an authorized prescriber. | All nonprescription medications have been taken out of the home and properly disposed of. |
10/17/2025
| Implemented |
|
|
|
SIN-00234971
|
Renewal
|
10/11/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature read 123 degrees in the kitchen. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water tank temperature control was adjusted down on 10/11/2023 and temp was rechecked 4 hours after. Water now reads 116°F. |
10/11/2023
| Implemented |
| 6400.106 | The furnace inspection is past due, with it last completed on 5/22/22. | 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.
| Rehoboth Inc director reached out to the contractor to request for copy document of inspection performed before inspections. |
10/16/2023
| Implemented |
| 6400.112(a) | Drills for December '22, and August, September, October '23 were not provided. | An unannounced fire drill shall be held at least once a month. | Effort was made to locate missing torn pages from Fire Drill Binder and duplicate in electronics binder...., |
10/11/2023
| Implemented |
| 6400.112(c) | Most of the fire drill forms did not answer which exit route was used, the evacuation time, whether the alarm was operable. | 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 or smoke detector was operative. | Rehoboth Inc conducted Fire drills refresher training to all employees with emphasis on evacuation time, exits route, schedule alternation Day/Night and whether alarm working or not. |
10/16/2023
| Implemented |
| 6400.112(e) | A sleep drill was not held at the required six-month interval (forms are too incomplete to determine) | A fire drill shall be held during sleeping hours at least every 6 months. | Rehoboth Inc conducted Fire drills refresher training to all employees with emphasis on evacuation time, exits route, schedule alternation Day/Night and whether alarm working or not. |
10/16/2023
| Implemented |
|
|
|
SIN-00220745
|
Unannounced Monitoring
|
03/09/2023
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Repeat Violation. There was evidence of rodent droppings in various kitchen cabinets. Home is currently being treated for infestation, but kitchen cabinets were not free from residue. | Clean and sanitary conditions shall be maintained in the home. | All the staff working in the house was trained and proper cleaning to include cabinets on daily basis.. |
03/20/2023
| Not Implemented |
| 6400.67(a) | The Living room ceiling light fixture had one lightbulb working out of 4 possible lightbulb fixtures. Individual 2's bedroom doorknob was loosely connected. | Floors, walls, ceilings and other surfaces shall be in good repair. | Residential Director added 3 more bulbs to ceiling light fixtures and re-tightened Individual 2 bedroom doorknob upon discovery. |
03/14/2023
| Not Implemented |
| 6400.72(b) | The vacant bedroom on the second floor next to individual 2's door had a broken screen off the window track. | Screens, windows and doors shall be in good repair. | The Residential Director repaired the screen upon discovery, it was blown off to the side by the wind. |
03/14/2023
| Not Implemented |
| 6400.110(a) | The second floor hall smoke detector did not function at the time of testing. Batteries were immediately replaced and the alarm subsequently functioned. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Batteries were immediately replaced during unannounced monitoring and now functions. |
03/14/2023
| Not Implemented |
| 6400.24 | An accurate count of the controlled substances needs to be kept per the controlled substance act of 1970. The Methylpenid ER 30mg prescribed to individual 2 had in inaccurate count. 50 tablets were present in the medication box however the log stated that there were 46 | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Medication audit was done with Staff and the Nurse . Carried over meds from previous month was assembled together in one place. The Staff was retrain on proper meds counting. |
03/10/2023
| Not Implemented |
| 6400.166(b) | Clonazepam prescribed to be taken twice daily at 8am and 8pm for individual 1 was not logged immediately after administration on March 3, 2023 in the morning. The field was left blank. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff Involved were retrained on medication documentation with focus on individual refusals. |
03/10/2023
| Not Implemented |
| 6400.166(c) | Individual 2 refused medications however there was not documentation of these refusals or follow up to the prescriber. The medication record provided no documentation of a refusal in the date box or on the back side. There was a dash in the initial box instead of any additional documentation. The medications which were refused are as follows:
- Docusate Sodium 100mg - take one tablet by mouth twice a day on
3/8/23 at 8pm
3/9/23 at 8am
- Methylpenid ER 30mg -- Take 2 capsules by mouth in morning on
3/9/23 at 8am
- Metoprol Suc ER 25mg tab -- Take one tablet by mouth daily on
3/9/23 at 8am
- Lamotrigine 100mg tab -- Take 1 tablet by mouth twice a day on
3/8/23 at 8pm
3/9/23 at 8am
- Quetiapine 200mg tab -- Take 1 tablet by mouth in the morning and 2 tablets by mouth at bedtime on
3/8/23 at 8pm
3/9/23 at 8am | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | Staff Involved were retrained on medication documentation with emphasis on individual refusals. |
03/20/2023
| Not Implemented |
|
|
|
SIN-00215919
|
Unannounced Monitoring
|
11/30/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There was a can of Raid brand spray left unlocked and accessible in the lower level of the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Director has bought additional locked shelve to secure any staff personal items that may be considered poisonous to our participant immediately after use |
11/30/2022
| Implemented |
| 6400.216(a) | Files for both individuals residing in the home containing personal information were left unlocked and unattended in the home. | An individual's records shall be kept locked when unattended.
| A section in our Locked Office Cabinet has been cleared and use for Individual record storage. |
12/01/2022
| Implemented |
| 6400.163(d) | Discontinued and excess medications were left unlocked in the lower level of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The Director took the Discontinued medications to Upper Darby Police Station Designated Discard medication box. |
12/01/2022
| Implemented |
|
|
|
SIN-00215224
|
Unannounced Monitoring
|
11/17/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There were several unlocked poisons found throughout the home including two Clorox bleaches, one container of laundry beads, all-purpose spray, and a Tub & Tile Repair kit, which contains several poisonous chemicals.
Champagne was also found unlocked in the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Clorox bleaches spray and tub kit was immediately removed and stored in a designated locked cabinet in the basement. Staff |
11/17/2022
| Implemented |
| 6400.64(a) | A substance consistent with mice droppings were present in areas where food is also stored. | Clean and sanitary conditions shall be maintained in the home. | The Director assigned Viking pest control to inspect the house for any traces of mice |
11/17/2022
| Implemented |
| 6400.66 | Several exits to the home lack adequate lighting. This includes the exit to the balcony off the second floor, as well as the main entrance of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Additional lights were installed on Exit to the balcony second floor, Main entrance, basement entrance. A picture exhibits 6, 7, 8 would be sent as proof of the installation |
11/22/2022
| Implemented |
| 6400.66 | The closet light in an upstairs bedroom is not able to be turned on or off easily as the pull string is wedged between two boards. This requires more than average pressure to control the power to operate the light and possibly can break the string. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The upstairs closest light was removed and replaced on 11/22/2022. |
11/22/2022
| Implemented |
| 6400.67(b) | A standing lamp is being used for a coat rack that still has light bulb attached. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Director got our client consent to agree to relocate the Standing lamp into a storage. It was moved out his room on 11/17/22 |
11/17/2022
| Implemented |
| 6400.71 | There were no emergency telephone numbers listed near any of the phones in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The emergency telephone numbers frame been rehung on the wall next to phone. To be sent on picture exh 9 |
11/17/2022
| Implemented |
| 6400.72(b) | The door jam in the bedroom belonging to Individual #1 is broken. | Screens, windows and doors shall be in good repair. | The door jam in Individual No 1 room was replaced on 11/30/2022. Pic Exh. 10 as proof |
11/30/2022
| Implemented |
| 6400.72(b) | The top of the door frame of the second-floor exit is bent causing the door not to open properly. | Screens, windows and doors shall be in good repair. | The door top frame of second floor exit was modify and repaired on 11/22/2022 |
11/22/2022
| Implemented |
| 6400.73(a) | The third-floor interior railing was loose and poses a falling hazard. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The 3rd-floor interior railing was re-tightened on 11/22/2022 |
11/22/2022
| Implemented |
| 6400.73(b) | There was secondary fencing on second level exterior balcony/handrail only secured with zip ties on exterior second floor balcony. | Each porch that has over an 18-inch drop shall have a well-secured railing. | The zip ties were for flower fix. And all fixing railing were re-inspected to be intact |
11/30/2022
| Implemented |
| 6400.74 | The exterior steps are extremely steep and should have a non-slip surface when exiting the building. | Interior stairs and outside steps shall have a nonskid surface.
| There is ongoing renovation to be completed later in the day today to add nonskid surface to existing steps |
12/02/2022
| Implemented |
| 6400.76(a) | The headboards in both bedrooms are unstable and can be easily swayed with little pressure. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Beds frames were retightened on . |
11/30/2022
| Implemented |
| 6400.80(b) | The exterior conditions of the home contain several large items of garbage and construction debris. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The rear exterior of the home with construction/garbage debris is now totally removed as at 11/30/2022. |
11/30/2022
| Implemented |
| 6400.144 | Regarding Medication review for Individual #1: The medication Methylpenid 36 mg tab blister pack was empty and there were no refills present. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Methypenid 36 mg a national shortage aware by individual psychiatrist. Rehoboth Inc director and Nurse prior got the psychiatrist to change the prescription prior to visit. Evidence by Doc Exh 10 of his psychiatrist visit. Another prescribed now in place. |
11/18/2022
| Implemented |
| 6400.144 | Regarding Medication review for Individual #2: The medication Invega Trinza 819 mg Injection was not present at the time of inspection. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Invega Trinza 819 mg injection. A one in 3 months injection only deliver by pharmacy few days before due date. The Nurse on 11.17.22 train all staff to be well informed to provide information regarding injection information of its availability. |
11/17/2022
| Implemented |
| 6400.32(h) | The bedroom door belonging to Individual #1 does not lock. | An individual has the right to privacy of person and possessions. | The door repair was completed on 11/30/2022. |
11/30/2022
| Implemented |
| 6400.163(g) | Medications for both Individuals were stored together in one plastic bag in a cabinet with food and dishes. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The cabinet was fully cleaned on 11/17/2022 |
11/17/2022
| Implemented |
| 6400.163(h) | Regarding the medication review for Individual #2: Clonazapam was present at the time of inspection but was not listed on the MAR. CEO states he believes this medication was discontinued. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The clonazepam was discontinued. It is now taken to police station for discard with pic evidence to sent |
12/02/2022
| Implemented |
| 6400.166(a)(2) | The prescriber information is not included on the MAR for both Individuals. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The prescriber information is now included on the MAr to be show on Exh 12 |
11/30/2022
| Implemented |
|
|
|
SIN-00209329
|
Renewal
|
08/02/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Criminal History Check for staff member #1 was completed on 8/1/22 however her date of hire was 11/1/21. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes 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.
| Criminal Background Check Staff Member #1 has been used as reference point to create a checklist to follow by the Director when hiring staff at rehoboth inc Criminal Background is now on No 1 on our check list. |
08/18/2022
| Implemented |
| 6400.66 | There was insufficient lighting in the dining room area as well as the outdoor side deck. Both had light fixtures that were non operable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Insufficient Lighting in the dinning room area as well as the outdoor side deck were corrected by replacing the bulbs by the director. |
08/18/2022
| Implemented |
| 6400.67(b) | The deck on the second story has floorboards that had been removed during a previous repair and have not been replaced.
The ground next to he house had broken glass as a result of a recently replaced window. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Rehoboth Inc Director evaluated the hazard and .summoned the contractor to completed the repair ongoing in the surface arear. Repairs were completed. After the Director inspected the repairs to be now free of hazards . This check marked by a check that was just created. |
08/18/2022
| Implemented |
| 6400.72(a) | There is no screen present in the bathroom window next to the bedroom of individual #1. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The director requested the contractor to install actual fit screen to the bathroom window. Director inspected it is well installed and marked it present on a walk through check list created. |
08/18/2022
| Implemented |
| 6400.101 | The side exit was locked and requires a key in order to unlock. This is a fire evacuation hazard and needs to be changed to a deadbolt. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Director immediately called in a contractor on the inspection to replace the lock with a key to a deadbolt lock. Staff were re- trained by the director on fire safety with important of easy evacuation |
08/18/2022
| Implemented |
| 6400.110(a) | Smoke alarm not operational on top story. It was out of batteries at start of inspection. Batteries were replaced and it still said low batteries but did work at time of fire tested fire drill. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Rehoboth Inc Director bought and replace the non working batteries.
Rehoboth Director assigned himself or the program director to be responsible for Bi weekly walk through to ensure batteries always working. |
08/18/2022
| Implemented |
| 6400.141(a) | The most recent annual physical on file for individual #1 occurred on 5/13/21, greater than one year prior to inspection. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Specialist involved individual #1 document now have a checklist in place to check and initial annual physical for all individual is within one year range.
Also, verification of actual form to take for annual visits has checked by the by the program specialist.
Annual Physical examination has been scheduled for individual #1 by the program specialist. |
08/18/2022
| Implemented |
| 6400.151(a) | The physical exam for staff member #1 was dated 10/6/20 however their date of hire was 11/1/21 which is greater than one year. | 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Director and Program Specialist involved hiring process now have a checklist in place to check and initial annual physical of staff is within one year range prior to hiring dates. |
08/18/2022
| Implemented |
| 6400.181(e)(14) | In the assessment dated 12/20/21 for individual #1 it does not state his ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual knowledge of water safety and ability to swim be has been listed to be discussed and updated in his annual ISP review meeting with the support Coordinator. |
08/18/2022
| Implemented |
| 6400.165(g) | There were no 3 month psychiatric medication reviews provided for individual #1 | 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. | Director called to schedule Psychiatric medication review for individual #1, Added to waiting list for date availability on physician calendar. |
08/22/2022
| Implemented |
|
|
|
SIN-00171048
|
Renewal
|
02/19/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The Kitchen was unkempt, there were dirty pots in the sink and items scattered on the counter due to lack of storage, and the stove was covered in a greasy substance. | Clean and sanitary conditions shall be maintained in the home. | During Validation, agency showed the kitchen was cleaned and organized. Former tenants of the property that resided at property no longer reside at the location. |
04/06/2020
| Implemented |
| 6400.64(f) | There was approximately 10 filled Garbage Bags in the back of the property that were not in covered cans. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The CEO has ordered new two closed receptacles for garbage bags. placed outside on 03/05/2020.
In order to prevent reoccurrence, CEO will retrain all staff (responsible for ensuring trash outside the home to be in closed receptacles in order to prevent the penetration of insects and rodents on 55 PA Code Chapter 6400.64(f) |
03/05/2020
| Implemented |
| 6400.65 | The ceiling ventilation fan in the first floor bathroom was inoperable at the time of physical site review | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The agency repaired the hood vent so that it was functional and verified the repair during validation. Routine maintenance checks will ensure vent stays operational. |
04/06/2020
| Implemented |
| 6400.66 | The main space of the basement had no lighting , the bathroom on third level also had insufficient lighting | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Ceiling light fixtures were installed and functional during validation to improve lighting in both the basement and third level office bathroom. |
04/06/2020
| Implemented |
| 6400.68(b) | The water temperature in the 2nd floor main bathroom tub measured 136.2 degrees Fahrenheit at the time of review | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The CEO immediately reduced the Hot water tank temperature to 118- degree f. after inspection on 02/19/2020. The CEO will complete hot water temperature inspections weekly and document compliance with 55 PA Code Chapter 6400.68(b) on the Licensing Inspection Instrument Score Sheet Section Physical Site. the CEO will retrain all staff (responsible for conducting daily temperature check on hot water system) on 55 PA Code Chapter 6400.68(b) |
02/19/2020
| Implemented |
| 6400.72(b) | The door leading to basement from the first level did not close entirely.
The window Blinds were damaged on 1st and 3rd floors at the time of physical site review. | Screens, windows and doors shall be in good repair. | The CEO ordered new lock and installed on 03/05/2020 and blinds were replaced.
In order to prevent reoccurrence, CEO will retrain all staff (responsible for reporting need for any screens windows and doors in need of repairs) on 55 PA Code Chapter 6400.72(b) |
03/05/2020
| Implemented |
| 6400.76(a) | Dryer lint was found in the dryer at the time of physical site review
Dining room chairs were not sturdy, the seats were not connected to the seat frame on two out of the four chairs. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The CEO immediately removed the lint after inspection on 02/19/2020. The CEO will complete dryer and washer inspections weekly and document compliance with 55 PA Code Chapter 6400.76(a) on the Licensing Inspection Instrument Score Sheet Section Physical Site. All areas of non-compliance will result in a maintenance request to be fixed and staff retraining. - In order to prevent reoccurrence, the CEO will retrain all staff on 55 PA Code Chapter 6400.76(a) |
02/19/2020
| Implemented |
| 6400.80(b) | There was loose trash around the exterior of the property, such as broken glass windows, bottles and debris, charcoal lighter fluid, and old plumbing. The external grounds were not well maintained. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The CEO has removed all trash around the property due to a new windows recently installed. Trash, and all debris removed on 03/05/2020.
In order to prevent reoccurrence, CEO will retrain all staff (responsible for maintaining neat outdoor environment and prevention of unsafe environment) on 55 PA Code Chapter 6400.110(b) |
03/05/2020
| Implemented |
| 6400.82(f) | There was no mirror, soap, or hand towel on the first floor bathroom, the second floor main bathroom also had no hand towel. | 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. | The CEO has purchased new mirror, stock soaps and hand towels, placed on 03/05/2020.
In order to prevent reoccurrence, CEO will retrain all staff (responsible for ensuring soap, toilet paper and hand towel never gone missing in all the bathrooms in our location) on 55 PA Code Chapter 6400.110(f) |
03/05/2020
| Implemented |
| 6400.110(a) | There were no working smoke alarms on the first floor and no smoke alarm was found on third floor. Alarms on first floor were missing batteries at the time of inspection and were in the living area on the floor.[Repeat violation from 11/14/18] | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 1. The CEO has purchased new interconnected smoke detectors batteries to the smoke detectors that was placed on the window and installed on 03/05/2020.
In order to prevent reoccurrence, CEO will retrain all staff (responsible for conducting all fire drills and checking fire systems and put emphasis on how to reset detectors when activated by smokes ) on 55 PA Code Chapter 6400.110(e) |
03/05/2020
| Implemented |
| 6400.110(e) | The smoke detectors were not interconnected at the time of physical site review. There was only one working smoke detector during inspection (second floor detector). The home had four levels including the basement. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The CEO has purchased new interconnected smoke detectors batteries and installed on 03/05/2020.
In order to prevent reoccurrence, CEO will retrain all staff (responsible for conducting all fire drills and checking fire systems) on 55 PA Code Chapter 6400.110(e) |
03/05/2020
| Implemented |
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SIN-00145229
|
Initial review
|
11/14/2018
|
Compliant - Finalized
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|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(a) | There were no smoke detectors on each floor. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Interconnected Smokes detectors have been purchase and installed on each floor / each room and hall ways.
The CEO will be responsible for correcting such problem in the future by periodically testing the smoke detectors that are in place whenever the current one damaged or when the battery is out
-It will be the practice of Rehoboth Inc. facility to hold fire drills at unexpected times under varying conditions, at least quarterly on each shift.
Times of fire drills will be monitored by Shift Supervisor and documented .
Rehoboth Fire Safety Procedure will be used to train all staff.
FIRE SAFETY
Fire represents a potentially life-threatening situation. It is essential that all employees be familiar with actions to be taken in case of fire.
Rescue any person in immediate danger.
Alert the fire department by calling 911.
Close all doors, if possible, to prevent or slow the spread of smoke or fire.
Extinguish the fire with a fire extinguisher if you can do so safely.
The staff shall report the status of the consumer to the CEO or management designee and emergency management personnel.
The staff shall report the condition of the home/building to the CEO or management designee and emergency management personnel. |
11/19/2018
| Implemented |
| 6400.111(a) | The fire extinguishers in the basement, main floor, second floor, and third floor were all rated 1A. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 2-A ratings Fire Extinguisher have been purchase and installed on each floor.
The CEO will be responsible for correcting such problem in the future by ensuring correct rated fire extinguisher is in place whenever the current one damaged, used or expired.
All staff will be trained about the necessity of having a correct 2-A rating fire extinguisher in place on each floor;
- Rehoboth Fire Safety Procedure will be used to train all staff.
FIRE SAFETY
Fire represents a potentially life-threatening situation. It is essential that all employees be familiar with actions to be taken in case of fire.
Rescue any person in immediate danger.
Alert the fire department by calling 911.
Close all doors, if possible, to prevent or slow the spread of smoke or fire.
Extinguish the fire with a fire extinguisher if you can do so safely.
The staff shall report the status of the consumer to the CEO or management designee and emergency management personnel.
The staff shall report the condition of the home/building to the CEO or management designee and emergency management personnel. |
11/19/2018
| Implemented |
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SIN-00253734
|
Renewal
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10/17/2024
|
Compliant - Finalized
|
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