Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270086 Renewal 07/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons shall be locked in this home. At the time of the inspection there was a cabinet in the basement filled with Clorox, laundry detergent and other cleaning supplies that was not locked.Poisonous materials shall be kept locked or made inaccessible to individuals. The cabinet in the basement containing Clorox, laundry detergent, and other cleaning supplies was immediately secured with a lock. 07/30/2025 Implemented
6400.68(a)The home shall have hot and cold running water under pressure. The temperature of the shower was only registering at 82.3 degrees which is too low. The bathroom sink was registering at 124 degrees which would be over the 122 degree maximum required by regulation.A home shall have hot and cold running water under pressure. Maintenance calibrated the boiler and managed to fix the fix the temperature discrepancy and ensure that hot water does not go above 120 degrees 07/04/2024 Implemented
6400.142(c)A written record of the dental exam shall include the date of the exam, the dentist's name, procedures completed and follow up treatment, the exam shall also include teeth cleaning or checking of the gums or dentures if applicable. The dental exam dated 8.28.24 only documented "regular check up". It is unable to be determined what procedures were completed by the lack of info completed on the dental form.A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. The dentist¿s office was contacted to obtain a detailed record for the 8/28/24 dental exam, including procedures completed and any follow-up treatment. The updated documentation was placed in the individual¿s file. 07/30/2025 Implemented
6400.151(a)Staff in direct contact with individuals shall have a physical 12 months prior to employment and every 2 years after. Staff #3 date of hire was 4.25.25 and his physical was dated 4.30.25. There is no grace period for initial staff physicals. 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. Staff #3¿s physical was completed on 4/30/25, after the date of hire but before start date 07/30/2024 Implemented
6400.181(e)(12)Individual #'s annual assessment dated 3.6.25 did not specify recommendations for areas of training programming or services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The annual assessment was updated to include clear recommendations for the individual¿s specific training, programming, and service needs. The revised document was signed and filed. 08/05/2025 Implemented
6400.181(e)(13)(i)Individual #1 annual assessment dated 3.6.25 did not list the individual's progress and growth over the past year in the area of health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The assessment was amended to document the individual¿s significant health problems and medical care needs, based on current medical records. 08/05/2025 Implemented
6400.181(e)(13)(ii)Individual #1 annual assessment dated 3.6.25 did not list the individual's progress and growth over the past year in the area of motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The assessment was updated to document the individual¿s progress and current level in both motor and communication skills, as required 08/05/2025 Implemented
6400.181(e)(13)(iii)Individual #1 annual assessment dated 3.6.25 did not list the individual's progress and growth over the past year in the area of activities of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. The assessment was updated to document the individual¿s needs for assistance with activities of daily living. 08/05/2025 Implemented
6400.181(e)(13)(iv)Individual #1 annual assessment dated 3.6.25 did not list the individual's progress and growth over the past year in the area of personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The assessment was updated to reflect the individual¿s personal adjustment, including adaptation to living environment and interpersonal relationships. 08/05/2025 Implemented
6400.181(e)(13)(v)Individual #1 annual assessment dated 3.6.25 did not list the individual's progress and growth over the past year in the area of socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The assessment was updated to include information on the individual¿s socialization skills and opportunities. 08/05/2025 Implemented
6400.181(e)(13)(vi)Individual #1 annual assessment dated 3.6.25 did not list the individual's progress and growth over the past year in the area of 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. The assessment was updated to include the individual¿s recreation interests and participation. 08/05/2025 Implemented
6400.181(e)(13)(vii)Individual #1 annual assessment dated 3.6.25 did not list the individual's progress and growth over the past year in the area of financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The assessment was updated to document the individual¿s current level of financial independence, including ability to manage money and any supports needed. 08/05/2025 Implemented
6400.32(r)Individual #2's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions expected by this regulation.An individual has the right to lock the individual's bedroom door.The privacy lock on Individual #2¿s bedroom door was replaced with a lock that meets the requirement for privacy and security, allowing the individual to lock their door. 07/31/2025 Implemented
6400.44(c)(3)The program specialist shall have at minimum an associate's degree with 60-hour credits from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism. Staff #1 is hired under the capacity as the program specialist. Staff #1 did not have higher education post her high school diploma.A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism.Documentation verifying the program specialist¿s education and required work experience is being obtained and a waiver is in the process of submission. An interim Program Specialist has been put in place as of 7/30/2025 07/30/2025 Implemented
6400.169(d)·Staff #2 training file only included the print off pages from the electronic test results. The dates documented for observation checks #2 #3 and #4 were completed on 4.30.25. Observation check #1 was not dated. A record of the training shall be kept, including the person trained, the date, the source, the name of the trainer and the documentation that the course was completed successfully.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Staff #2¿s medication administration training file was updated to include complete records for all four observation checks, with the missing date for Observation #1 added. Documentation now includes the staff name, training dates, course source, trainer¿s name, and proof of successful completion. 08/04/2025 Implemented
SIN-00247210 Renewal 07/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #2 was hired on 12/05/2023 and a Pennsylvania criminal history record check was not completed until 2/28/2024, more than two months after the staff was hired and began working with individuals.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. The issue with Staff #2¿s Pennsylvania criminal history record check has been resolved, with the check completed on 2/28/2024 07/24/2024 Implemented
6400.141(c)(11)The annual physical examination completed on 1/08/2024 for Individual #1 did not include documentation of the health maintenance needs of the individual. (There was a line for this with yes/no checkmarks -- yes was checked but there was no additional information or instruction for health maintenance needs).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. The annual physical examination for Individual #1 lacking an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals has been corrected by having the physical form filled out by the primary care doctor and the above missing information was included 08/26/2024 Implemented
6400.141(c)(14)The annual physical examination completed on 1/08/2024 for Individual #1 did not include documentation of information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The annual physical examination for Individual #1 lacking Medical information pertinent to diagnosis and treatment in case of an emergency has been corrected by having the physical form filled out by the primary care doctor and including any missing information 08/26/2024 Implemented
6400.141(c)(15)The annual physical examination completed on 1/08/2024 for Individual #1 did not include documentation of the individual's recommended diet or special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. The annual physical examination for Individual #1 lacking documentation of the recommended diet and special dietary instructions has been corrected by having the physical form filled out by the primary care doctor and including any missing information 08/26/2024 Implemented
6400.142(f)Individual #1 did not have a dental hygiene plan in their record.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The issue of Individual #1 lacking a dental hygiene plan in their record has been corrected, with a comprehensive dental hygiene plan now documented and included in their file by the clinical director 08/11/2024 Implemented
6400.151(a)Staff #2 did not complete a physical examination within 12 months prior to the date of hire. Staff #2 was hired on 12/05/2023 and did not complete a physical examination until 1/24/2024. 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 issue regarding Staff #2¿s physical examination has been corrected, with the examination completed on 1/24/2024. 07/24/2024 Implemented
6400.151(b)The physical examination that Staff #3 completed on 3/03/2024 (date of hire 4/08/2024) was not signed or dated by the medical provider. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Staff #3's physical examination form was returned, to the medical provider for proper signing and dating, ensuring the document is fully validated. 08/05/2024 Implemented
6400.181(e)(4)The initial assessment completed on 2/24/2024 for Individual #1 did not contain documentation of the individual's supervision needs, required staff ratios, level of supervision necessary (i.e. eye sight range, same room, etc.) and frequency of checks when the individual is alone in their bedroom. The information that is contained in the assessment regarding supervision is very vague and provides no guidance regarding the individual's 2:1 staffing needs. Individual #1 is currently being staffed at a 2:1 level "for safety" but there is no specific information in the document identifying whose safety and/or safety from what is required. The assessment states that the individual can have "safely unsupervised time in the home" and that the individual "can be in his room alone with staff regularly checking in" on the individual, but the assessment does not specify how frequently staff should conduct those checks. The assessment states that the individual "may remain on the property alone with staff on the premises" but does not specify where staff should be in relation to the individual. The assessment must include the following information: The individual's need for supervision. The initial assessment for Individual #1 was revised immediately to include detailed documentation of the individual's specific supervision needs, including the required staff ratios, levels of supervision necessary (e.g., eyesight range, same room), and the exact frequency of checks when the individual is alone in their bedroom has been updated to every 15 minutes. The assessment also clarified the reason for the 2:1 staffing, specifying whose safety is being addressed and from what risks. 08/01/2024 Implemented
6400.181(e)(9)The initial assessment completed on 2/24/2024 for Individual #1 did not contain documentation of the individual's disability, including functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. The initial assessment for Individual #1 will be updated immediately to include comprehensive documentation of the individual's disability, covering both functional and medical limitations. The assessment will be reviewed with the clinical director, to ensure accuracy and completeness. Moving forward, all initial assessments will be carefully reviewed for thorough documentation of all required details, including disability-related information, before being finalized. Staff involved in completing assessments will receive additional training on the importance of fully documenting these aspects. As a preventative measure, a checklist will be implemented to ensure that all required elements are included in each assessment, and regular audits will be conducted to verify compliance. 08/26/2024 Implemented
6400.32(v)The individual rights statement reviewed with and signed on 1/05/2024 did not include: an individual's rights may only be modified to the extent necessary to mitigate a significant health or safety risk to the individual or others.An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.To correct this, the individual rights statement for the document signed on 1/05/2024 will be revised to include the language stating that an individual's rights may only be modified to mitigate a significant health or safety risk to the individual or others. 07/31/2024 Implemented
6400.51(b)(4)There was no documentation that Staff #1 (date of hire 11/30/2023) and Staff #3 (date of hire 4/08/2024) completed training in recognizing and reporting incidents as a required part of orientation training.The orientation must encompass the following areas: recognizing and reporting incidents.Both staff #1 and #3 had completed the Relias training on Writing incident reports which did not meet regulatory requirements. Both staff had ODP trainings on Recognizing and Reporting Incidents completed on December 14th and March 12th respectively 08/01/2024 Implemented
6400.165(g)Individual #1 had a review of psychiatric medication on 5/08/2024 and the record of the visit did not document the reason for prescribing the medication, the need to continue the medication and the necessary dosage of the medication.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.The psychiatric medication review record for Individual #1 was be updated to include the reason for prescribing the medication, the need to continue it, and the necessary dosage. The psychiatrist was contacted to provide the missing details. 08/28/2024 Implemented
6400.166(a)(9)The medication administration record (MAR) for Individual #1 did not record a frequency of administration for the pro re nata (PRN) medication polyethylene glycol 3350 powder.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.The medication administration record (MAR) for Individual #1 was be updated immediately to include the frequency of administration for the PRN medication, polyethylene glycol 3350 powder. 08/26/2024 Implemented
6400.166(a)(11)The medication administration record (MAR) for Individual #1 did not record a diagnosis or purpose for the pro re nata (PRN) medication polyethylene glycol 3350 powder.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.The medication administration record (MAR) for Individual #1 will be updated immediately to include the diagnosis and purpose for the PRN medication, polyethylene glycol 3350 powder. 08/26/2024 Implemented
SIN-00227138 Initial review 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The basement staircase leading to a bilco-door exit and had five steps but no handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. 1. Handrail installed on the basement staircase leading to a bilco-door exit on 7/6/23. Images will be sent to the email provided for reference. 07/06/2023 Implemented
6400.110(e)The home has three levels and the smoke detectors were not interconnected.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. 1. New interconnected fire alarms were bought and installed on each floor. Testing was done to confirm audibility and interconnection. 07/06/2023 Implemented