| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00275415
|
Renewal
|
10/08/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(1) | Individual #1's assessment dated 09/18/25 did not include the following information: the preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The individual's assessment will include in more depth and explanation, the functional strength, needs and preference of the individual. |
06/30/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment dated 09/18/25 did not include the following information: the individual's need for supervision. The assessment indicated Individual #1 was new to the residence and still being assessed. Individual #1 has resided in the residence for approximately 10 months. | The assessment must include the following information: The individual's need for supervision.
| The assessment of the individual will include more detailed information the individuals need for supervision in the areas of home and community. |
06/30/2026
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment dated 09/18/25 did not include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials; the assessment simply checked a box indicating the individual had an "Adequate Awareness." | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The individual's assessment will be completed to include more explanation and more in depth to include the individuals' ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. |
06/30/2026
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment dated 09/18/25 did not include the following information: the individual's knowledge of water safety and ability to swim; the assessment simply checked a box indicating the individual had an "Adequate Awareness." | 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. | The assessment will be updated to include more explanation and be more in depth to include: The individual's progress over the last 365 days and current level in the following areas: The individual's knowledge of water safety and ability to swim. |
06/30/2026
| Implemented |
| 6400.165(d) | Individual #1 had a "Over the Counter Medication Form; Resident medical information/physician consent form signed by the physician and dated 9/18/25. The following medication were prescribed and approved by the physician: Tylenol (Acetaminophen); 325mg. Advil (Ibuprofen): 200mg., Tussin DM (dextromethorphan HBr/guaifenesin), Guaifenesin (Mucinex): 600mg., Maalox or Mylanta: 20ml., Pepto-Bismol 30ml., Milk of magnesia 30m., Imodium (loperamide HCI) 2mg., Debrox ear drops or generic equivalent, Saline nasal spray, Cortisone cream, diphenhydramine (Benadryl or generic equivalent) 25-50mg., Benzocaine (Oragel, Anbesol, Cepacoll or generic equivalent, Osteo bi-flex pain relieving cream )Menthol 5%/Methyl salicylate 10%). The above medications were not used only by the individual who was prescribed the medication and at times shared by others. | A prescription medication shall be used only by the individual for whom the prescription was prescribed. | The individuals OTC medications will no longer be used by any person other than the one labeled on the medication. Effective immediately, each OTC will be assigned to only one individual. |
06/30/2026
| Implemented |
| 6400.182(c) | Individual #1's Individual Service Plan, (ISP), last updated on 9/3/25, contained a discrepancy between the current assessment dated 9/18/25 in the domain of supervision. Individual's assessment dated 9/18/25 indicates, "Individual #1 was new to the residence and still being assessed." The ISP dated 9/3/25 indicated Individual #1 can be left unsupervised in the community up to 3 hours. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The discrepancies in the assessment will be corrected immediately to show the individual's ability to be left unsupervised in the community for up to three hours. |
06/30/2026
| Implemented |
|
|
|
SIN-00255325
|
Renewal
|
10/22/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | On 10/23/2024 at approximately 10:05am, Individual #3's bedroom did not contain a mirror. Individual #3 signed a declination on 11/24/2021 indicating that they did not wish to have a mirror in their bedroom for fear of breaking it; however, the Individual's Support Plan, last updated 10/15/2024, had not been updated to reflect this choice. | In bedrooms, each individual shall have the following: A mirror. | Each individual will have a mirror in their bedroom. If they choose not to have a mirror in their bedroom, their decision will be indicated on their annual assessment. |
06/30/2025
| Implemented |
| 6400.181(e)(8) | Individual #2's current assessment, completed 6/21/2024, did not include an assessment of the individual's ability to evacuate in the event of a fire. This section was omitted from the Individual's assessment. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Assessment will clearly indicate the ability of the individual to evacuate in the event of a fire. |
06/30/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's current assessment, completed 10/15/2024, did not include a copy of the individual's psychological evaluation. According to Individual #1's Individual Support Plan, last updated 9/23/2024, a psychological evaluation was completed on 11/8/2007. The agency did not have documentation of any attempts made to obtain a copy of this evaluation prior to the violation being identified by licensing personnel. | The assessment must include the following information: Psychological evaluations, if applicable. | The assessment will include psychological evaluations. If one in not able to be obtained, then every effort to obtain one will be documented. |
06/30/2025
| Implemented |
| 6400.166(a)(7) | Individual #2 is prescribed Ibuprofen 200mg-400mg caplets to be administered every 4-6 hours as needed for minor aches and pain or to reduce a fever. On 10/23/2024 at approximately 10:24am, Individual #2's October 2024 Medication Administration Record listed the dose of the medication to be administered as "200mg". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Medication record shall be kept for each individual. The medication administration record for the proper dose of medication. |
06/30/2025
| Implemented |
| 6400.166(a)(9) | Individual #2 is prescribed Ibuprofen 200mg-400mg caplets to be administered every 4-6 hours as needed for minor aches and pain or to reduce a fever. On 10/23/2024 at approximately 10:24am, Individual #2's October 2024 Medication Administration Record listed the frequency of the administration as "3 times daily···PRN". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Medication record shall be kept for each individual. The medication administration record for the frequency of the medication. |
06/30/2025
| Implemented |
|
|
|
SIN-00234303
|
Renewal
|
11/07/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 11/8/2023 at 10:31am, the water temperature in the kitchen sink measured 125.0°F. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | We will be placing digital thermometers on handheld showers that will help staff and individuals identify the temperature before using the shower. We will be replacing all regulators on the water heater sources in the very near future. |
06/30/2024
| Implemented |
| 6400.112(f) | All fire drills conducted at this location between 10/18/2022 and 10/17/2023 utilized the front door as the exit route. There is an alternate exit route on the side of the house, leading down the stairs adjacent to the kitchen. | Alternate exit routes shall be used during fire drills. | There will be a remediation training for all agency Supervisors and Directors during an Administration monthly meeting. This remediation will review the entire 55 PA Code Chapter 6400.112 to include 6400.112(f). The agency Director of Compliance will check all the fire drills done within the agency every six months to ensure the entire 6400.112 code is being followed. |
06/30/2024
| Implemented |
|
|
|
SIN-00142440
|
Renewal
|
09/18/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1, admission date 5/21/18, initially signed the statement acknowledging receipt of the information on individual rights on 5/24/18. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | 1. Mandatory meeting for all management staff educating all clinical managers that the Individual Handbook which contains all individuals rights will be given to individual on day of admission. 55PA Code Chapter 6400.31(b).
2. All new admissions will have Individual Handbook completed and signed on day of admission. Copies to be sent to CEO on day of admission.
Responsibility: Deborah L. Price, CEO; All Residential Directors; All Residential Supervisors;
Correction Date: 09/21/2018 and repeated on 10/23/2018. |
09/21/2018
| Implemented |
| 6400.101 | The door leading to the attic of the home was equipped with a padlock locking system preventing egress from the attic when engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 1. Padlock removed and replaced with a breakaway door knob. Opens without a key from exit side of door.
2. All homes checked for locks preventing egress, none found. 55 PA Code Chapter 6400.101
Responsibility: Deborah L. Price, CEO; Fred Raszmann, Maintenance Worker |
09/21/2018
| Implemented |
| 6400.113(a) | Individual #1, admission date 5/21/18, had initial fire safety training on 5/25/18. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, 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 home. | 1. Mandatory meetings for all management staff educating all clinical managers that fire training will be done on first day of admission, 55 PA Code Chapter 6400.113(a).
2. All new admissions will have fire training completed and copies sent to CEO on day of admission.
Responsibility: Deborah L. Price, CEO; All Residential Directors; All Residential Supervisors;
Correction Date: 9/21/2018 and repeated on 10/23/2018. |
09/21/2018
| Implemented |
|
|
|
SIN-00215084
|
Renewal
|
11/08/2022
|
Compliant - Finalized
|
|
|
SIN-00181608
|
Renewal
|
01/19/2021
|
Compliant - Finalized
|
|
|
SIN-00162674
|
Renewal
|
09/04/2019
|
Compliant - Finalized
|
|
|
SIN-00122871
|
Renewal
|
10/11/2017
|
Compliant - Finalized
|
|
|
SIN-00060229
|
Renewal
|
09/18/2014
|
Compliant - Finalized
|
|
|
SIN-00048353
|
Renewal
|
04/18/2013
|
Compliant - Finalized
|
|