Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253198 Renewal 09/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no medical tape present in the first aid kit. 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. The tape was used earlier that morning but not returned to the first aid kit.. Picture attachment # 4 shows the tape back in the first aid kit within hours of the kit being inspected. The supplies of first aid kit was added to the house check form attachment #6 will be checked weekly by the nurse, it was not on the prior form attachment #7. the nurse will be responsible for supplying the contents of the first aid kit within 24 hours in the event something is missing. 10/01/2024 Implemented
6400.24Under the 1970 Controlled Substances Act, all class c medications must be double locked and counted at each administration of the medication. The controlled substances in the home were not double locked or being counted.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The controlled substance form was obtained by the M-5 nurse who oversaw that the correct medication, strength and administration was noted on the form. From September 27th to the 30th the nurse trained the staff to the use of the form, which included marking the count of all pills in the blister pack, how many were given and how many are left, signing the form, and reporting to the nurse any counts that are off or mistakes.Attachment #3 is the controlled substance form, The use of the controlled substance form attachment #3 began on October 1, 2024. In the locked closet is now the med box with the controlled substance with a lock, the picture of the locked med box is attachment #5. 10/01/2024 Implemented
SIN-00213226 Renewal 09/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual 1's last TB test was completed on 9/24/2020. Record did not include a new test, which was due by 9/24/2022.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. This was an unusual circumstance, the individual 1's PCP abruptly retired the month she was due for a physical , a new PCP was later secured however we had to use Urgent Care Tower Health on 11/11/2022 to the TB test. 11/11/2022 Implemented
6400.141(c)(7)Individual 1's last gyn exam was completed on 9/21/2021. There was not an updated GYN exam completed by 9/21/2022The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual 1's GYN was completed 10/11/2022, at that appointment the mammogram was ordered and completed 11/8/2022. We will follow medical doctors recommendations. Document #9 11/08/2022 Implemented
6400.195(b)Individual 1's BSP was not reviewed by the provider's HRCThe behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The behavior support component of individual 1 will be specifically noted that it was reviewed by the team at the monthly review meetings. document #10 10/11/2022 Implemented
SIN-00193627 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)In the bathroom located in individual #1's bedroom there were bars around the toilet for stability and lifting. The one bars to the right looking towards the toilet was loose and unstable. Floors, walls, ceilings and other surfaces shall be free of hazards.A work order was placed, the grab bars around the toilet in individual #1 bathroom were secured. See attachment #15 10/01/2021 Implemented
6400.72(a)There were no screens on the window in individual #2's bedroom.Windows, including windows in doors, shall be securely screened when windows or doors are open. Individual #2 is on two allergy medications Nasonex Nasal Spray and Loratadine for her allergies. Due to her allergies her window does not get opened, this is why there is no screen. Individual #1 has an air conditioner in her bedroom window. See attachment #16(first page of physical) and #17(medication list) 10/19/2021 Implemented
SIN-00176915 Renewal 09/24/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Staff Member #1's fire safety training was not completed within the annual timeframe. It was completed 9/3/19, and then 9/22/2020.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Due to COVID-19 the fire safety training for this non front line(direct care) was less than 20 days late it was completed during the same month it was due. Our goal was to make sure are direct care staff were trained in a timely manner as they are the staff at the houses. If there was not a pandemic the program specialist would received training on schedule. The CEO will schedule annual fire safety training . 09/25/2020 Implemented
6400.62(d)There was a cabinet in the kitchen that had chemicals such as bleach stored with food items.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Staff were verbally reminded, and all agency staff received the attached #10 memo about the proper storage of chemicals not to be stored with food. The CEO sent memo to all staff and program specialist verbally reminding. 10/20/2020 Implemented
SIN-00124619 Renewal 10/24/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The annual physical examination dated 8/24/2017 for Individual #1 did not document health maintenance needs and need for blood work.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 physical form will be reviewed by the M-5 nurse and director to make sure the health maintenance needs, the need for blood work, and any additional tests or follow-up care is documented by the physician; any areas not addressed or left blank will require returning the physical to the physician for completion. 10/27/2017 Implemented
SIN-00106083 Renewal 12/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The toilet paper holder was missing from the second floor bathroom. 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 bathroom had toilet paper however the licensing representative wanted it to be on a holder. A toilet paper holder stand was purchased and is in the bathroom. In the future to avoid another non compliance in this area toilet paper will be placed on the holder. 12/06/2016 Implemented
6400.141(c)(14)Individual #4¿s annual physical dated 9/19/16 did not indicate information pertinent to diagnosis or treatment in case of emergencyThe physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Medical information was inserted on the emergency treatment section of physical instead of "see M-5 hospital visitation form". However the physical is not a changing document therefore does not capture any health issues until the next annual physical To avoid future non compliance "in case of emergency was added to physical with the diagnosis, 12/06/2016 Implemented
6400.181(e)(5)Individual #4¿s annual assessment dated 9/9/16 did not assess the individual¿s ability to self-medicate. The assessment must include the following information:  The individual's ability to self-administer medications.The information under medication administration was enhanced by adding the individual cannot differentiate one medication from another, she relies on staff for this skill, she cannot remember how often to take medication but she is very good taking the medication from staff and placing it in her mouth. In the future to avoid non compliance information in this area will be detailed. 12/06/2016 Implemented
6400.181(e)(14)Individual #4¿s annual assessment date 9/9/16 did not indicate the individual¿s knowledge of water safety or their 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. At the time of the inspection on 12/1 and 12/2, 2016 the assessment had under water safety the individual adjust water temperature independently. She is able to judge if the water is too hot to be tolerated and has no need for caution in this area. Under swimming it had "She does not swim". To avoid a noncompliance in the future this was added: The individual does not have the ability to swim. 12/06/2016 Implemented
6400.183(4)Individual #4¿s annual ISP dated 1/5/16 did not indicate a protocol/schedule outlining time without direct supervision. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. The ISP for this individual does include a protocol/schedule for being without direct supervision it has "periodic line of sight, she can be alone in her room as long as she chooses" in the community she is accompanied by staff for protection from exploitation. In the future to avoid a non compliance this area will be highlighted. 12/06/2016 Implemented
SIN-00073654 Renewal 03/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)The assessment for Individual #1 was dated 4/1/14 and was completed after the ISP meeting of 2/25/14. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. We updated our schedule list for 2015-16 for doing assessments to coincide with the plan meeting dates to enable the assessment to be mailed to Supports Coordinator at least 30 days prior to the plan meeting. A copy will be scanned and emailed to you. 05/01/2015 Implemented
6400.181(f)There is no specific date documented that indicates Individual #1's assessment was sent to the SC prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The cover letter that accompanies the assessment mailed to the Supports Coordinator was revised to include both the date it was mailed, and the date she received it. The Supports Coordinator must sign and date and return this receipt when she receives it. A copy will be scanned and emailed to you. 05/01/2015 Implemented
SIN-00058538 Renewal 03/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Staff person A's Mantoux skin test was completed on 1/29/14 and the staff's date of hire was 11-10-13. (2) 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 new staff person in question had an active valid TB test at the point when she started work. It however expired 29 days after her hire date and she didn¿t renew it until a month and a half later. In the future , if staff don't renew their TB test by it's expiration we will place them on leave until they acquire a new TB test. 04/10/2014 Implemented
6400.181(e)(5)Individual #1's assessment dated 12-3-13 did not include the ability to self-administer medications.(5)  The individual's ability to self-administer medications.We created a new template for our Assessments to make sure all future assessments do not overlook any of the points covered by 6400.181. We then corrected the Assessment for this individual adding the missing information concerning her ability to self-administer A copy of the corrected Assessment will be sent under separate cover. 04/10/2014 Implemented
6400.181(e)(7)Individual #1's assessment dated 12-3-13 did not include the ability to avoid heat sources.(7) The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. We created a new template for our Assessments to make sure all future assessments do not overlook any of the points covered by 6400.181. We then corrected the Assessment for this individual adding the missing information concerning her ability to avoid heat surfaces over 120 degrees. A copy of the corrected Assessment will be sent under separate cover. 04/10/2014 Implemented
6400.181(e)(8)Individual #1's assessment dated 12-3-13 did not include the ability to evacuate in the event of a fire.(8) The individual's ability to evacuate in the event of a fire. We created a new template for our Assessments to make sure all future assessments do not overlook any of the points covered by 6400.181. We then corrected the Assessment for this individual adding the missing information concerning her ability to evacuate in case of fire. A copy of the corrected Assessment will be sent under separate cover. 04/10/2014 Implemented
6400.181(e)(13)(i)(e) The assessment must include the following information: (i) Health. (ii) Motor and communication skills. (iii) Activities of residential living. (iv) Personal adjustment. (v) Socialization. (vi) Recreation. (vii) Financial independence. (viii) Managing personal property. (ix) Community-integration. Violation: Individual #1's assessment dated 12-3-13 did address progress and growth in all required areas. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health (ii) Motor and communication skills (iii) Activities of residential living (iv) Personal adjustment (v) Socialization (vi) Recreation (vii) Financial independence (viii) Managing personal property (ix) Community-integration We created a new template for our Assessments to make sure all future assessments do not overlook any of the points covered by 6400.181. We then corrected the Assessment for this individual adding all the missing information . A copy of the corrected Assessment will be sent under separate cover. 04/10/2014 Implemented
6400.188(c)Individual #1's ISP dated 3-6-13 identifies family contact and community involvement as needed outcomes. There was no protocol to determine how progress on the outcomes would be measured.(c) The residential home shall provide services to the individual as specified in the individual's ISP. Our current Monthly Reports will be more inclusive and more fully reflect the monthly progress toward each goal listed in the ISP. In addition to the current listing in our Monthly Reports of family contact and community activities, we will report how these contacts and activities were arranged and how she responded to them. 04/20/2014 Implemented
SIN-00048162 Renewal 03/26/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1 did not have a crimminal history check prior to the hire date of 5/28/12.(a) 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. 6400.21(a) Staff person YG had a crime check on file from prior to her date of hire. However, she had stopped working for two years after her husband¿s death. Upon returning to work, we did not do a second crime check. We did do a second one on March 26, 2013 when we discovered this was in error. Effective 3/26/13 we will do additional crime checks for anyone who returns to work after a lengthy absence of not working. 03/26/2013 Implemented
6400.181(f)The date of the assessment and the ISP mtg. date of 3/20/12 were listed as the same. The assessment was not completed 30 days prior to the ISP meeting and sent to the supports coordinator.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). We have updated and adapted our In-house ISP calendar to make sure the information on our updates to the ISP are received by the Casemanager before the 30 days prior to the scheduled ISP meeting date effective 3/26/13. 03/26/2013 Implemented
6400.186(a)The 3 month reviews of 2/13, 11/12, 8/12 and 5/12 for individual # 1 did not discuss progress and growth from the recommendations listed in the assessment.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. We will continue to do our Quarterly ISP and ASSESSMENT reviews as we have been doing with the addition of a section devoted to specific progress on the recommendations, and outcomes listed in the Assessment and ISP for the quarter being reviewed. Effective March 2013 ... see enclosed additions to the quarterly reports for HM and LS. Done on 4/22/13. 04/22/2013 Implemented
SIN-00231980 Renewal 09/27/2023 Compliant - Finalized
SIN-00149523 Renewal 01/31/2019 Compliant - Finalized