Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280765 Renewal 01/05/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)CPR Training took place 1/2/26. However, Staff One was hired on 3/20/25. Staff needs to be trained in emergency training with in 6 months from date of hire.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.Beyond Care Services acknowledges that Staff One completed CPR training on 1/2/26; however, the training did not occur within six (6) months of the staff member's hire date of 3/20/25 as required. To correct this noncompliance, Beyond Care Services has verified that Staff One has now completed CPR training conducted by an individual certified through a recognized health care organization. Documentation verifying completion of CPR, first aid, and Heimlich training has been placed in Staff One's personnel file. 01/05/2026 Implemented
6400.163(h)PRN prescribed as Docusate SOD 250mg Cap, dispensed 8/19/2025, use by 8/19/2026 for Individual One was found in the medication box with other PRN medications but not listed on the MAR.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Beyond Care Services acknowledges that a PRN medication (Docusate Sodium 250 mg capsule), dispensed on 8/19/2025 with a use-by date of 8/19/2026 for Individual One, was found in the medication box with other PRN medications but was not listed on the Medication Administration Record (MAR). To correct this issue, the medication was immediately reviewed to determine its current status. As the medication was not listed on the MAR and not authorized for administration, it was removed from active medication storage. The medication was destroyed in a safe and appropriate manner in accordance with Federal and State statutes and regulations, and documentation of disposal was completed. All current medications were reviewed against the MAR to ensure accuracy and consistency between prescribed medications and documentation. 01/05/2026 Implemented
6400.213(1)(i)Next of Kin: not listed in Individual One's file - incident report states no family but annual assessment states that there's a sister, cousin and grandmother.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Beyond Care Services acknowledges that Next of Kin information was not consistently documented in Individual One's record. While the incident report indicated no family involvement, the annual assessment identified the presence of a sister, cousin, and grandmother. To correct this issue, Beyond Care Services has reviewed and updated Individual One's record to accurately reflect Next of Kin information based on the most current and verified assessment data. The individual's personal information section has been updated to ensure consistency across all documentation, and clarification has been documented to resolve discrepancies between records. 01/05/2026 Implemented
SIN-00272616 Unannounced Monitoring 08/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)There is a signed Room and Board contract between the provider and Individual #1, dated 04/04/2025; however, expense records and receipts show that Individual #1 was charged for multiple grocery purchases in July and August 2025. As part of the Board agreement, the provider is responsible for these types of purchases.Individual funds and property shall be used for the individual's benefit. The individual was never billed or held financially responsible for groceries. The provider has adhered to the requirements of the signed Room and Board agreement. To strengthen compliance and enhance documentation practices moving forward, the provider will ensure that financial records and supporting documentation clearly reflect that grocery purchases are covered by the agency in accordance with the contract. The Chief Executive Officer will monitor this process and is responsible for ensuring continued compliance. 08/18/2025 Implemented
6400.22(e)(3)For July and August 2025, the provider was unable to provide documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of Individual #1. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. The provider will ensure that all purchases exceeding $15 made on behalf of Individual #1 are supported by an original receipt or verifiable expense record. Effective immediately, staff will be required to submit receipts for all purchases at the time of transaction. Administrative staff will maintain these records in the individual¿s financial file, in accordance with 55 Pa. Code Chapter 6400 regulations. 08/25/2025 Implemented
6400.43(b)(1)There is a signed Room and Board contract between the provider and Individual #1, dated 04/04/2025; however, expense records and receipts show that Individual #1 was charged for multiple grocery purchases in July and August 2025. As part of the Board agreement, the provider is responsible for these types of purchases.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. The individual was never billed or financially responsible for groceries. The provider has adhered to the requirements of the signed Room and Board agreement. To strengthen compliance and enhance documentation practices moving forward, the provider will ensure that financial records and supporting documentation clearly reflect that grocery purchases are covered by the agency in accordance with the contract. 08/25/2025 Implemented
6400.64(a)Throughout the basement, baseboards and various parts of drywall closest to the basement floor were discolored and appeared to be water damaged. Additionally, there were two (2) chairs in the basement with cushions covered in a spotted, mold-like substance.Clean and sanitary conditions shall be maintained in the home. The provider has removed and disposed of the two (2) chairs with mold-like substance to eliminate any potential health and safety risk. The affected baseboards and sections of drywall were inspected, cleaned, and replaced where necessary. A licensed contractor was engaged to assess and remediate the water damage and ensure the area is safe and sanitary. 08/18/2025 Implemented
6400.64(f)The trash receptacle in the backyard did not have a cover/lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The provider immediately replaced the trash receptacle with one that includes a secure cover/lid to prevent pest access and maintain sanitary conditions. 08/15/2025 Implemented
6400.67(b)Broken tiles were found on the edge of the stairwell landing leading from the top of the 2nd floor down to the 1st floor. The broken floor tiles present a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The provider immediately removed and replaced the broken floor tiles on the stairwell landing to eliminate the tripping hazard and ensure a safe walking surface. A maintenance inspection was completed to verify that the repair met safety standards. 08/18/2025 Implemented
6400.70The home was not equipped with an operable, non-coin-operated telephone with an outside line that is easily accessible to individuals and staff.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The provider immediately added a cordless, non¿coin-operated landline telephone with an outside line to the home to ensure accessibility for both individuals and staff. The phone has been installed in a common area that is easily reachable and will remain operable at all times. 08/18/2025 Implemented
6400.71Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center could not be found posted on or near a telephone or in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The provider immediately posted the emergency telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center in a visible location near the home¿s landline telephone. The posting is clear, legible, and accessible to both staff and individuals in the event of an emergency. 08/18/2025 Implemented
6400.72(a)The window covering on the first-floor bathroom window was torn and no longer covered the full window.Windows, including windows in doors, shall be securely screened when windows or doors are open. The provider immediately removed the damaged window covering and replaced it with a new, fully functional covering that ensures the window is completely covered and privacy is maintained at all times. 08/19/2025 Implemented
6400.76(a)Dining room chair legs on one (1) chair were loose and not stable enough to safely sit in the chair. Furniture and equipment shall be nonhazardous, clean and sturdy. The provider immediately removed the unstable dining room chair from use. The chair was repaired to restore stability and safety, and the dining area was re-inspected to ensure all other chairs and furniture are secure and safe for use. 08/19/2025 Implemented
6400.80(b)Trash, debris, and discarded furniture were observed throughout the backyard area. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The provider immediately removed all trash, debris, and discarded furniture from the backyard. The area was cleaned and restored to a safe and sanitary condition. 08/15/2025 Implemented
6400.111(a)All floors of the home, including the basement, were equipped with fire extinguishers that do not meet the minimum required 2-A rating for each floor.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. All floors of the home, including the basement, were equipped with fire extinguishers that meet the minimum required 2-A rating for each floor. 08/18/2025 Implemented
6400.111(c)The kitchen was not equipped with an operable fire extinguisher that meets the minimum required 2A-10BC rating. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). The provider immediately removed the non-compliant fire extinguishers and replaced them with fire extinguishers that meet or exceed the minimum 2-A rating requirement for every level of the home, including the basement. Documentation of purchase and installation has been retained in agency records. 08/18/2025 Implemented