Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263418 Renewal 04/01/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #2's most recent physical exams were greater than one year apart. The dates of the exams were 6/14/23 and 7/22/24.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. A physical assessment appointment has been made with the PCP for Individual #2 on 7/31/2025. Expiration date of Individual #2's physical is 7/22/2025. All appointments are made by the individual mother/legal guardian. 04/11/2025 Implemented
6400.151(a)Staff #1 was hired on 8/19/22 and did not have a physical exam in the records for the initial physical exams nor the two-year follow-up exam. There was no annual physical on file for staff #2, who is the CEO but also functions as the program specialist for the agency. 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. Physical Assessments have been completed for Staff #1 and staff #2 on 4/8/2025. 04/08/2025 Implemented
6400.181(d)The program specialist did not sign individual #2's 6/24/24 annual assessment.The program specialist shall sign and date the assessment. Program Specialist found the signed copy of the assessment and will make sure to sign all assessments in the future. 04/11/2025 Implemented
6400.217Individual #2's consent to obtain information that in his file was signed by his legal guardian on 4/29/23. The form states that it is only valid until 4/24/24. No new consent is present in the file.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. Written consent form for Individual #2 has been completed on 4/11/2025 by the individual's legal guardian/mother. 04/11/2025 Implemented
6400.34(a)Individual rights for individual #2 were not reviewed and signed annually. The copy on file was last signed 6/1/23.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual rights form for Individual #2 has been completed on 4/7/2025 by his mother/legal guardian. 04/07/2025 Implemented
6400.166(a)(2)The Name of the prescriber was missing on the following medications for Individual #2: · Guanfacine 2mg, 1 tab, 2 times per day 8a and 12pm · Lamotrizine 200 mg 1 tab 2 times daily 8a and 8p. · Sertraline Hcl 100mg 2tabs 8a · Lorazepam 2mg, 1-tab, 8a and 2pA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Optimal will be switching to Community Care RX pharmacy, 7601 Castor Avenue, Philadelphia, PA. New MAR will reflect the prescribing physician, medication, dosage, time, route, and reason. Letters were sent to each physician based on the individual's prescriptions, reason for medication, and to confirm all medication details. Moving forward, Community Care RX will be creating the MAR and updating the MAR when changes occur. 05/01/2025 Implemented
6400.166(a)(11)Diagnosis or purpose for the medication was not noted on the medication administration record (MAR) of Individual #2 for the following medications: · Divalproex Sod DR 500g 8a and 8p · Guanfacine 2mg 2 times per day 8a and 12pm · Lamotrizine 200 mg 1 tab 2 times daily 8a and 8p. · Sertraline Hcl 100mg 2tabs 8a · Lorazepam 2mg 1 tab 8a and 2pA 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.Optimal will be switching to Community Care RX pharmacy, 7601 Castor Avenue, Philadelphia, PA. New MAR will reflect the prescribing physician, medication, dosage, time, route, and reason. Letters were sent to each physician based on the individual's prescriptions, reason for medication, and to confirm all medication details. Moving forward, Community Care RX will be creating the MAR and updating the MAR when changes occur. 05/01/2025 Implemented
SIN-00246187 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104104 THE LETTER TO THE FIRE DEPT WAS NOT UPDATED, IT LISTs TWO INDIVIDUALS instead of one.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. Program Specialist updated the letter to the fire department to reflect there is one individual in the home. Program Specialist also mailed the letter to the fire department and a copy of the floor plans outline the individual's bedroom. 05/14/2024 Implemented
6400.112(e)112 NO ASLEEP DRILLS CONDUCTED FOR THE YEARA fire drill shall be held during sleeping hours at least every 6 months. House manager completed the fire drill during sleeping hours in May (5/1/24). Please see attached fire drill notes 05/01/2024 Implemented
6400.113(a)The individual number 1 was not trained in annual general fire safety 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. Behavioral Specialist is assisting Optimal in creating a story with pictures to help the individual understand the importance of leaving the house during a fire. 06/10/2024 Implemented
6400.144144 Medication FANAPT 6mg in medication box but not on the MARHealth 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. Program Specialist discarded all of the discharged medication including Fanapt. 04/02/2024 Implemented
6400.144144 Medication DAIRY FIBER had no label from a pharmacy that expired on 02/2024Health 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. Program Specialist will discard all discharged medication (Fiber). 04/02/2024 Implemented
6400.151(a)Annual physical for staff number 2 prior to working not completed (DOH 9/20/23). On file is a physical dated 4/1/24. NO physical on within 12 months prior to employment, 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. Program Specialist will utilize pre hiring checklist that includes a physical as a requirement. 04/02/2024 Implemented
6400.151(b)151 (b) A physical examination for staff number 1 was never completed, signed, and dated by a licensed physician, staff should have a physical within 12 months prior to employment and every 2 years thereafter. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Program Specialist will utilize pre- hiring checklist that includes physical as a requirement 04/02/2024 Implemented
6400.213(5)213 (5) There was no written Dental plan in the records for individual number 1.Each individual's record must include the following information: Dental hygiene plans. House Manager will request Dental plan at upcoming dental appointment 6/28. Individual attended appointment on 6/28 but refused to open mouth. Dentist stated it was not able to provide a plan because due to the individuals refusal. 04/02/2024 Implemented
6400.165(b)165 (b) Medication KETOCLONPAZOLE 2% SHAMPOO expired on 07/2023, medication IBUPROFEN TAB 06/03/2023, medication ACETAMINOPHE TAB 325mg expired 06/03/2023, and medication CLONAZEPAM 2mg (expired in 07/2023).A prescription order shall be kept current.Program Specialist will discard the expired medication immediately 04/02/2024 Implemented
6400.165(c)165 (c) Medication (CLOBETASOL PROPIONATE) is not being administered as prescribed. (Medication is to be given on Saturday and Sunday) being given every day.A prescription medication shall be administered as prescribed.Program Specialist will modify the MARS to reflect the administration of medication on Saturday and Sunday only. The MARS was updated to reflect the medication is only to be given on Saturday and Sunday by crossing out the other days of the week to prevent medication errors 04/02/2024 Implemented
6400.169(c)(2)169 (c)(2) The Medication Administration Training for staff number 1 was completed on 07/25/2023, the staff trainer did not sign or date that the training was completed.A staff person may administer an epinephrine injection by means of an auto-injection device in response to anaphylaxis or another serious allergic reaction following successful completion of both: Training within the past 24 months relating to the use of an auto-injection epinephrine injection device provided by a professional who is licensed, certified or registered by the Department of State in the health care field.The Staff Member signed the medication administration training on 4/2/24 04/02/2024 Implemented
6400.181(f)181f there was no proof that the current assessment was sent to the ISP teamThe program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program Specialist gave a copy to the SC and Behavior Specilalist during the last ISP. Effective immediately, Program specialist will send the assessment via email 30 days prior to the ISP meeting. 04/02/2024 Implemented
6400.183(c)183 c No ISP meeting sign in sheet was in the record to show at least 3 persons attended the plan meeting.The list of persons who participated in the individual plan meeting shall be kept.Program Specialist will contact the SC for the sign in sheet for the lat ISP. Although all parties signed the attendance sheet, when the Program Specialist contacted the SC it was reported the signature page could not be located 04/02/2024 Implemented
SIN-00231205 Unannounced Monitoring 09/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The closet door in individual number one's bedroom is off the door jam and needs to be repaired. Also, the closet door in the office is jammed, unable to open and close, and needs to be repaired.Windows, including windows in doors, shall be securely screened when windows or doors are open. Closet door will be fixed. Optimal Lifestyle has a maintenance person that will be assigned to fix the issue with the door. 10/28/2023 Implemented
6400.181(d)The current assessment for individual number one was not signed or dated.The program specialist shall sign and date the assessment. Individual assessment was signed. 09/28/2023 Implemented
6400.166(a)(9)The medication administration record for individual number one incorrectly states that the prescribed Vitamin D-3 2000 dietary supplement should be taken 2 times per day. The prescription for Vitamin D-3 2000 units tablet states "take 1 tablet by mouth every day".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.MAR was updated to reflect the change in frequency of administration for the Vitamin D3 supplement. 09/28/2023 Implemented
6400.181(f)The provider did not have records showing that the current assessment was sent to the Plan team. What was communicated was that the assessment was given to the team at the ISP meeting on 8/1/2023, therefore the assessment was not provided to the team 30 calendar days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Everyone on the individuals team has a copy of the most current assessment. A new SC was just assigned to the case and she was emailed a copy of it as well. 09/28/2023 Implemented
6400.195(b)The provider has a practice in place where the staff are required to lock the refrigerator and freezer in order to prevent individual number 1 from overeating. The provider's record shows that this individual has a history of excessive overeating and is taking medication (Tamomax) that is intended to decrease this overeating behavior, however this restriction is not covered in the behavior support plan. The behavior plan needs to be updated to reflect this practice and how to educate the individual on their condition.The 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 plan was updated to reflect the restriction. A meeting will be scheduled with the members of the team including the legal guardian of the individual. 10/28/2023 Implemented
6400.195(b)Individual number one has a current behavior support plan that is being implemented by staff, however the plan has not been reviewed by the provider's human rights team within the past 6 months.The 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 human rights team will schedule a meeting which will include the legal guardian of the individual. In this meeting we will discuss the behavioral support component and will do this quarterly. 10/28/2023 Implemented
SIN-00222604 Renewal 04/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)There is no physical for Individual #1.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Our Program specialist is the person responsible for monitoring and ensuring compliance with this issue. The individual has an upcoming doctors appointment with his PCP. We have requested the completion of a physical examination. Once completed we will receive a copy of it. Program Specialist will also make sure that the individuals we support complete their physical exams prior to onboarding and maintain compliance annually. In each individuals folder we will include a log of physical exams to track and make sure thy are done in time. We will also add the Physical Exam as an item in our Participant Checklist which is used to gather all necessary documentation required prior to accepting a new client. This way we can make sure physical exams are done in a timely manner. 06/20/2023 Implemented
6400.181(a)There is no assessment for Individual #1. 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. The individual reviewed did not have an assessment done by our agency. Our program specialist will be responsible for completing the initial assessment and continue doing them yearly. In addition we will create an assessment log that will track the dates each assessment was completed and attach the written assessments to it. We will also add the initial assessment to our Participant Checklist which is used to gather all necessary documentation required prior to accepting a new client. This way we can make sure our initial assessments are done in a timely manner. 06/20/2023 Implemented
6400.34(b)There is no individual rights form for Individual #1.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.The individual reviewed or their legal guardian did not sign an Individual Rights form. Optimal Lifestyle will create a document that informs all participants and their legal guardians of their rights while attending our program. This task is to be fulfilled by our program specialist. The form will then be signed by the individual and / or their legal guardian. The item Participant Individual Rights will be then added to our Participant Checklist which is used to gather all necessary documentation required prior to accepting a new client. This way we can make sure the Individual Rights form is signed before someone enters our program and maintain compliance thereafter. 06/20/2023 Implemented
6400.165(g)There are no psychotropic medication reviews 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.The individual reviewed did complete a recent appointment with a psychiatrist and all psych meds have been reviewed. We will contact the providers office and gather all documentation required in this regulation. Our program specialist will be the person designated to ensure compliance with this item. We will also require a psych med review every 3 months and document all needed information about psychotropic medications. In order to track compliance we will develop a tracker / checklist that will ensure medication reviews are done. 06/20/2023 Implemented