Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280274 Renewal 12/30/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff Person #2 has a hire date of 5/5/2025, however the criminal background check was not completed until 7/9/2025.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. Human Resources was reeducated on 12/30/25 on the regulatory requires for running criminal background checks. 01/10/2026 Implemented
6400.67(a)There appeared to be a leak in the ceiling of the third-floor bathroom. It was explained that a known issue with exhaust fan condensation was the cause.Floors, walls, ceilings and other surfaces shall be in good repair. On 12/30/2025 WHHC maintenance team was notified about the ceiling and exhaust fan. This was completed 1/10/2026 03/05/2026 Implemented
6400.68(b)The water temperature exceeded the allowable 120 degrees.. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 12/30/25 WHHC maintenance team adjusted the water temperature for the residence 01/08/2026 Implemented
6400.72(a)The third-floor's three windows lacked screens.Windows, including windows in doors, shall be securely screened when windows or doors are open. On 12/30/25 WHHC maintenance team replaced the screens in the home. 01/08/2026 Implemented
6400.73(a)The banister from the first to the second floor was not secure as it moved when used. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 12/30/25 WHHC maintenance team properly reinforced the banister in the home 01/08/2026 Implemented
6400.110(e)The interconnected fire alarm system did not sound together when activated.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. On 12/30/25 WHHC maintenance team was notified about the issues with the alarm system New intercom system was ordered 1/10/26 This will be installed by the WHHC maintenance department. 03/12/2026 Implemented
6400.112(e)From 1/1/2025 through 12/2025, one sleep drill conducted on 2/14/2025, 6am.A fire drill shall be held during sleeping hours at least every 6 months. On 12/30/25 staff were re-educated on the proper methods to do a sleep drill. Staff were informed that there needs to be a minimum 2 drills per year overnight. 01/05/2026 Implemented
6400.24Rent is being charged in excess of 72% of SSI and SSP. The room and board agreement signed on 3/27/2025 states rent is 848.88 for Individual #2. The maximum rent for 2025 for any individual is $712.15.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.On 12/30/2025 WHHS management started the process of reimbursement for funds. Residents were refunded their rent 1/10/26. 01/10/2026 Implemented
6400.163(h)Several random pills were observed in the bottom of the medication container that housed Individual #2's medication.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.On 12/30/25 staff were re-educated on the proper way to administer medication by utilizing the dates on the blister packs as well as signed on meds being given. 01/08/2026 Implemented
6400.166(a)(11)It was observed on the MAR and medication labels that the diagnosis or purpose for a medication's issuance was inconsistently included for Individual #2.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.On 12/30/25 staff were re-educated on the proper way to administer medication by utilizing the dates on the blister packs as well as signed on meds being given. 01/01/2026 Implemented
6400.167(a)(1)On December 29 and 30, 2025, numerous instances were observed where it appeared medicine was signed as administered to Individual #2 but appeared in the blister pack. Refusals were noted but not for all days when the discrepancies occurred. There were no notes on the back of the MAR to indicate the Provider's policy was followed for a medication refusal.Medication errors include the following: Failure to administer a medication.On 12/30/25 staff were re-educated on the proper way to administer medication by utilizing the dates on the blister packs as well as signed on meds being given. 01/08/2026 Implemented
6400.167(a)(3)A discrepancy was observed between the MAR and blister packet labeling for Individual #2. The MAR indicated at 8pm Divalproex 250mg was prescribed one by mouth at 8pm, but the label read take 2 tabs by mouth twice a day at 8am and 8pm but for a 500mg tab. There were only 500mg tabs available for administration.Medication errors include the following: Administration of the wrong dose of medication.On 12/30/25 staff were re-educated on the proper way to administer medication by utilizing the dates on the blister packs as well as signed on meds being given. 01/08/2026 Implemented
6400.194(d)There were no HRT meeting minutes on file for Individual #2 who currently has a restrictive behavior support plan in place.A record of the human rights team meetings shall be kept.On 12/30/25 WHHC HRT scheduled a meeting for HRT for individual 2. Meeting was held on 1/8/2026 01/08/2026 Implemented
SIN-00259604 Renewal 01/23/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 who was admitted on 12/14/24 did not have a physical until 1/3/25.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The Executive Director failed to obtain a copy of individual #1 physical prior to her admission to the program. On 1/23/25, the Executive Director created a reminder tickler system for individual #1 to schedule her annual exam three months prior to the due date. 03/10/2025 Implemented
6400.165(g)Individual #1 did not have psychotropic med reviews since admission.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 house supervisor failed to ensure that individual #1 had 3-month review of their psychotropic medications. On 1/23/25, individual #1 3-month psychotropic medication review scheduled with their doctor. 01/23/2025 Implemented
SIN-00246526 Renewal 04/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)The staff does not have a Pennsylvania criminal history record check within 5 working days after the date of hire or no more than 1 year prior to the person's date of hire. Staff $3 (03/13/24) DSP Staff#7 (03/13/24) DSP Staff #6 (03/13/24) DSP Staff #5 (03/13/24) DSP Staff #4 (03/19/24) DSP Staff #2 (03/13/24) House SupervisorAn 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 agency failed to provide the department with a copy of the staff criminal histry check at the time of the inspection. On 6/25/24 the Executive Director and HR complete an audit all staff files to ensure all staff working in the home had a background check completed within 5 days after the date of hire. 06/28/2024 Implemented
6400.106The furnace in the home did not have inspections completed.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. The agency failed to have a tickler system in place for the annual cleaning of the furnace. On 4/15/24, the house supervisor scheduled a furnace cleaning for the home. 06/25/2024 Implemented
6400.151(b)Documentation that the staff has a physical examination completed within 12 months prior to employment up to and including currently was not provided. (That includes free of communicable diseases and TB testing). The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The agency failed to provide the inspector with documentation of staff physical examination. On 4/20/24, the Executive Director provided the agency with the staff physical examination. 06/28/2024 Implemented
6400.151(b)Staff #3 works with individual daily and does not have a physical examination completed within 12 months prior to employment up to and including currently. (That includes free of communicable diseases and TB testing). The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The agency failed to ensure staff #3 had a completed physical examination prior to employment. On 4/15/24, the agency human resource department completed an audit of individual #3 personnel file. Staff #3 was scheduled for a physical examination. 06/28/2024 Implemented
6400.46(a)The Program specialists and direct service workers were not trained before working with individuals in general fire safety by a fire safety expert.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.The agency failed to provide the department with a copy of the staff fire safety training signature sheet. On 4/15/24 the house supervisor obtain a copy of the staff fire safety training sheet from the fire safety trainer. 06/28/2024 Implemented
6400.51(a)(1)Staff #3 did not complete orientation prior to working with the individual within 30 days after hire, staff was hired 03/13/24.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.The house supervisor failed to document the completion of staff # 3 orientation on the agency's orientation form. On 6/25/24, an orientation completion form was completed for staff #3 by the house supervisor. 06/28/2024 Implemented
6400.52(a)(3)Documentation of annual training was completed for the Staff #1 (program specialist) was not provided at time of inspection.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.The agency failed to have the program specialist's training record readily available at the time of the inspection. On 6/5/24, program specialist training record was provided to the department. 06/28/2024 Implemented
SIN-00239625 Initial review 01/03/2024 Compliant - Finalized