Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00286789 Renewal 04/08/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Grease and residual food crumbs were observed in the home's air fryer whereas clean and sanitary conditions are required to be maintained in the home.Clean and sanitary conditions shall be maintained in the home. The air fryer identified during the inspection was immediately cleaned and sanitized to remove all grease and residual food debris. The appliance was thoroughly washed, dried, and returned to proper use condition. At this time, the home is maintaining clean and sanitary conditions and is in compliance with the regulatory requirement. 04/08/2026 Implemented
6400.67(a)A leak was observed beneath the kitchen sink when the water was running, indicating it needed repair as required by regulation.Floors, walls, ceilings and other surfaces shall be in good repair. Upon identification, the leak beneath the kitchen sink was immediately reported and addressed. Maintenance was contacted, the source of the leak was identified, and the issue was repaired. The area beneath the sink was cleaned and dried to prevent damage or mold. At this time, the sink is functioning properly, all surfaces are in good repair, and the home is in compliance with the regulatory requirement. 04/27/2026 Implemented
6400.68(b)The bathroom tub registered 172 degrees which exceeded the allowable temperature of 120 degrees. (Repeat violation). Hot water temperatures in bathtubs and showers may not exceed 120°F. Upon discovery, staff immediately implemented an interim safety measure by regulating water at the point of use prior to each use to ensure a safe and appropriate temperature for the individual. Water temperatures were checked and documented in a log before each use to ensure health and safety. Prior to the inspection, UFIL INC had already identified concerns with elevated water temperatures and submitted multiple maintenance requests to the apartment complex to address the issue. During the inspection, a temperature reading of 172°F was recorded. Following the inspection on April 8, 2026, UFIL INC engaged a licensed plumber, and a thermostatic mixing valve was installed on April 9, 2026, which successfully reduced the water temperature to within safe limits. The apartment management team subsequently requested the removal of the device, as installation must be completed through their approved contractor process. UFIL INC is actively working with the apartment management team to obtain approval to install thermostatic mixing valves at points of use to ensure consistent and safe water temperatures. In addition, UFIL INC requested that the apartment management team address the issue at the source due to the urgency of the situation. Following this request, subsequent temperature readings taken by staff indicated that water temperatures had decreased, with recent readings showing levels within a safe range, including a reading of 99.7°F in the residence. As an added safeguard, staff will continue to monitor and document water temperatures and ensure safe water levels at the point of use until a permanent solution is approved and implemented to maintain consistent temperature control. 04/09/2026 Implemented
6400.111(a)The kitchen fire extinguisher's gauge indicated that it was under-pressurized, rendering it potentially inoperable when needed. At least one operable fire extinguisher is required for each floor by regulation.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The kitchen fire extinguisher identified as under-pressurized was immediately removed from service and returned to the vendor for servicing. The unit was repaired and restored to proper pressure levels to ensure it is fully operable and meets the required minimum 2-A rating. Upon return, the fire extinguisher was reinstalled and verified to be in operable condition. At this time, the home has at least one operable fire extinguisher on each floor and is in compliance with the regulatory requirement. 04/21/2026 Implemented
6400.34(a)Individual 2's consents and Individual rights have not been updated since 2024.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 2's consents and individual rights documentation were immediately reviewed and updated. The individual was provided with an explanation of their rights and the process to report a rights violation. The updated forms were completed and signed, and copies were placed in the individual's record. At this time, the home is in compliance with the regulatory requirement. 04/08/2026 Implemented
6400.165(b)Individual 2's medication administration record for PRNs included Artificial Tears Drops; however, the drops were not available in the home during the inspection.A prescription order shall be kept current.Upon discovery, Individual 2's medication administration record (MAR) was reviewed. At the time of inspection, staff had already initiated the process of obtaining the prescribed PRN medication (Artificial Tears Drops) from the pharmacy. The medication was promptly received and made available in the home. The medication was verified against the current prescription order to ensure accuracy. At this time, all prescribed medications listed on the MAR are present in the home, and the record is current and accurate. The home is now in compliance with the regulatory requirement. 04/08/2026 Implemented
6400.166(a)(11)Individual 2's medication administration record did not consistently include the required diagnosis or purpose for daily maintenance and PRN medications.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.Upon identification, Individual 2's medication administration record (MAR) was immediately reviewed. The required diagnosis or purpose for all medications, including daily and PRN medications, was added to the MAR to ensure accuracy and compliance with regulatory requirements. All medications were verified against current physician orders and supporting documentation to ensure completeness. At this time, the MAR accurately reflects the diagnosis or purpose for each medication, and the home is in compliance with the regulatory requirement. 04/28/2026 Implemented
SIN-00266455 Renewal 05/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)Staff Four and Five were hired on 8/15/24, yet Criminal History was not requested until 11/7/24.If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. The agency acknowledges the delay in requesting the background checks for Staff #4 and #5. This issue occurred due to an administrative oversight during onboarding. Once identified, the agency took immediate corrective action to ensure compliance. Pennsylvania State Police and FBI background checks were promptly initiated and have since been successfully completed. Both staff members were cleared and deemed eligible to continue providing direct support services. Documentation of their clearance results has been added to their personnel files, and the agency confirmed that there were no incidents during the interim period. Moving forward, the agency has taken steps to prevent similar lapses, as outlined below. 06/22/2025 Implemented
6400.68(b)The running water of the kitchen and bathroom returned with temperatures of 145.1F and 145.5F respectively, exceeding the allowable threshold of 120F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Daily water temperature checks are conducted by staff as part of the agency¿s routine environmental safety protocol. On April 30, 2025, staff recorded elevated hot water temperatures at the residence, which triggered an automated alert in the agency¿s internal monitoring system. In response, a maintenance request was promptly submitted to the apartment complex administration to lower the water heater setting. The apartment¿s maintenance team is currently addressing the issue. Additionally, the agency has requested that faucet limiters be installed at frequently used taps to restrict hot water output, and the front office has confirmed that this request is in progress. To ensure the immediate safety of Individual #3, a temporary safety protocol has been implemented. Staff are required to manually test water temperature at all faucets before use and assist the individual as needed to prevent accidental exposure to excessively hot water. All temperature logs, maintenance communications, and staff instructions have been documented and are available for review. Staff have also received re-training on water safety procedures and the importance of promptly reporting and escalating temperature concerns. 06/24/2025 Implemented
6400.111(f)The fire extinguisher in the kitchen (on the wall) did not have a inspection tag verifying that it has been checked annually. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The agency identified in December 2024 that the wall-mounted fire extinguisher provided by the apartment complex lacked a valid inspection tag and could not be confirmed as having been inspected by a certified fire safety expert. Since the extinguisher was not under the agency¿s control, a proactive decision was made at that time to purchase a new, agency-owned fire extinguisher that had been properly inspected and certified in accordance with 55 PA Code Chapter 6400.111(f). This compliant extinguisher was placed on the kitchen countertop in December 2024 and was already present in the apartment at the time of the annual inspection. To prevent confusion, the original wall-mounted extinguisher was subsequently removed and returned to the apartment complex after the inspection and following the exit meeting. The residence now contains only one fire extinguisher, which is properly certified, inspected, and fully compliant with regulatory requirements. 06/17/2025 Implemented
6400.46(d)The following Staff One was not trained in CPR/FA:Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Upon review, it was determined that Staff One had not completed the required CPR, First Aid, and Heimlich maneuver training within the mandated time frame. As corrective action, the staff member was immediately scheduled for and completed an in-person CPR/First Aid training conducted by a certified instructor affiliated with a recognized health care training organization. Certification credentials have been received and are available for licensing verification. Staff One is now in full compliance with the regulation. 06/16/2025 Implemented
6400.46(d)CPR records for the following staff two and three did not include an in-person training componentProgram specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Upon discovering that Staff Two and Staff Three did not complete the required in-person CPR/First Aid training, the agency conducted a comprehensive review of all staff CPR certifications. It was determined that additional staff across the agency had also completed only online CPR/First Aid courses without the required hands-on, in-person component. As a corrective measure, all affected staff, including Staff Two and Staff Three, were immediately scheduled and brought in for in-person CPR, First Aid, and Heimlich maneuver training conducted by a certified instructor affiliated with a recognized healthcare organization. All participants successfully completed the training and were issued updated certification verifying in-person instruction. These credentials have been reviewed and filed in each employee¿s personnel record and are available for licensing verification. Going forward, in-person CPR/First Aid training is now mandatory for all agency staff who provide direct support or supervision to individuals. Online-only certifications will no longer be accepted. This ensures full compliance with 55 PA Code Chapter 6400.46(d) and reinforces the agency¿s commitment to the safety and well-being of the individuals we serve. 06/19/2025 Implemented